Order No. 22  dt.  10/07/2017

The fact of the case in brief is that the complainant  was covered by a Family Health Optima Insurance Policy  issued by o.p. This insurance policy was purchased by her husband Amit Kedia to cover the complainant Richa Kedia and their sons Rishi Kedia and Yash Kedia. The sum assured was Rs.5,00,000/-. The first policy was purchased from Reliance General Insurance for the period from 24.03.2007 to 23.03.2008. The same was renewed from 24.03.2008 to 23.03.2009 and then such renewal continued and ultimately a changeover was made and similar insurance policy was taken from the o.p., Star Health for the period from 24.03.2011 to 23.03.2012 for a sum assured Rs.5,00,000/- covering the complainant, her husband Amit Kedia, their two sons Rishi Kedia and Yash Kedia and a total sum of Rs.8,466/- was paid  as premium. Such policy was issued along with a specific endorsement dated 24.03.2011 with continuous effect without any break to the extent of Rs.4,00,000/- for insured persons. The first year exclusions will not be applicable upto Rs.4,00,000/- for insured persons. During the period of policy coverage the complainant failed sick with stomach ailment and she was admitted to Belle Vue Clinic on 27.02.2013 and underwent medical treatment in the said hospital and she was discharged on 05.03.2013 for further treatment at Asian Institute of Gastroenterology, Hyderabad (AIG) from 06.03.2013 and she was discharged from said hospital on 09.03.2013. The complainant had to incur a medical expense  of Rs.1,37283/- at Belle Vue Clinic  and Rs.67,382/- at AIG, Hyderabad. Total expenditure incurred Rs.2,04,665/-.  The admission and progress note clearly states that the ailment paid in abdomen was about 3 years old. The insurance policy initially vide their letter dated 04.05.2013 repudiated the claim on the ground of exclusion no.10 i.e. ailment for which the medical expenses were  incurred was related  to treatment of psychiatric disorder thereafter the ground of repudiation was changed vide their letter dated 11.05.2013 for the ground of ‘pre-existing disease’. The pre-existing disease clause is effective for the first 4 years and in the instant case there was continuous insurance coverage for more than 6 years. The complainant also stated in her petition that there was no human being ever born who never suffered from any stomach pain or illness in his/her lifetime. In the 2^nd hospital, the hospital document erroneously declared that the stomach pain suffered by the patient was for 5 years vide certificated dated 25.03.2013. However, it was specifically recorded that there was no significant past history with the duration of illness. The certificate was later rectified by the certificate  dated 26.06.2013 wherein it was specifically stated that the pain in abdomen and vomiting was for 3 years. This rectified copy was duly forwarded to o.p. but they neglected to consider her claim. Hence the application praying for direction upon o.p. to pay a sum of Rs.2,02.881 along with compensation of Rs.25,000/- for harassment and mental agony and cost of  Rs.25,000/-.

          Sole o.p. contested the case by filing w.v. In their w/v o.p denied all material allegation inter alia stated that during 2^nd hospitalization the complainant was suffering from recurring pain in abdomen and vomiting since last 3 years has been diagnosed  as ‘Antral Gastritis and B12 deficiency’ which clearly appeared to have been deliberately concealed by her at the time of filling the proposal form. Hence the alleged claim is frivolous, vexatious and devoid of merits. The complainant is guilty of fraudulent suppression of material facts relating to her own past illness. The past history was not mentioned in discharge summary dated 05.03.2013 issued by Bell Vue Clinic.

          Ld lawyer for the o.p. cited the decision of Hon’ble National Consumer Dispute Redressal Commission, New Delhi( United India Insurance Co. Ltd. Vs Subhash Chandra, in Revision PetitionNo.469/2006 decided on 19^th May,2010), which clearly held that principle of insurance is fundamental to “utmost good faith”, which must be observed by the contracting parties and “utmost good faith” forbids either party from non-disclosure of the fact. In their w/v  o.p. cited several decisions of Hon’ble National Commission and the Hon’ble Supreme Court of India on the ground that if the complainant suppressed the material fact  then the insurance company is not liable to pay the claim.

          It is also mentioned in the w/v that the 2^nd hospitalization claim was repudiated under Exclusion clause 10 instead of Exclusion Clause 11 due to typographical error. However, the fate of the claim does not  change. The company is not liable to make any payment in respect of expense incurred at hospital for the treatment of psychiatric disorders.

          The insured patient as per medical certificate dated  26.06.2013 was suffering from recurring pain in abdomen and vomiting since 3 years This is prior to inception of policy taken from o.p. and hence this is a pre-existing disease since the 2^nd treatment was related to psychiatric  disorder. Hence the o.p. was left with no option but to repudiated the 2^nd claim. Hence o.p. prayed for dismissal of the instant complaint being frivolous vexation and devoid of merits with heavy costs.

Decision with reasons

We have gone through the pleadings of the parties and materials on record and evidence in particular. It is admitted fact that the complainant was under health Insurance coverage since the year 2007 and there was continuous coverage of the policy. The insured took the mediclaim policy from Reliance General Insurance for the period from 24.03.2007 to 23.03.2008. The same was renewed from 24.03.2008 to 23.03.2009 then such renewal continued and ultimately a changeover was made and similar insurance policy was taken from the o.p., Star Health for the period 24.03.2011 to 23.03.2012 for a sum assured Rs.5,00,000/- covering the complainant her husband Amit Kedia, their two sons Rishi Kedia and Yash Kedia a total sum of Rs.8,466/- was paid  as premium. Such policy was issued along with a specific endorsement dated 24.03.2011 with continuous effect without any break to the extent of Rs.4,00,000/- for insured persons. From Anneure B running page-13 we have observed the Endorsement issued by o.p. wherefrom it is evident that this insurance will be deemed to be continuous without any break to the extent of Rs.4,00.000/- for the insured persons. It is also stated in the document that  ‘in consequence of the above, the 30 days, 1^st year exclusion will not be applicable up to Rs.4,00,000/- for the insured persons’. Complainant was admitted in the Bell Vue on 27.02.2013 and she was discharged on 05.03.2013 with complaints of  severe pain at right upon abdomen radiating to back and severe vomiting. Then the complainant was admitted on 06.03.2013 in AIG and she was discharged on 09.03.2013. The insurance company firstly repudiated the claim of the complainant under exclusion clause 10 which is a dental treatment or surgery of any kind unless necessitated due to accidental injuries and requiring hospitalization. But in the w/v o.p. stated that it was typographical mistake and the exclusion clause would be 11 instead of clause 10. Clause 11 states convalescence, general debility, mental disorder, run-down condition or rest cure, congenital external disease  or defects or anomalies sterility, veneralo disease, intentional self injury and use of intoxicating drugs/alcohol. In this case though the discharge certificate issued by AIG diagnosed as ‘mixed anxiety with depression but this does not fall under the exclusion clause no.11

          In the 2^nd repudiation letter dated  11.05.2013 insurance company repudiated the claim on the ground of pre-existing disease. The document issued by AIG  reveals that the complainant was suffering from the disease for past 3 years. The endorsement dated 24.03.2011 issued by o.p. it is clear that the policy was a continuous policy which was started in the year 2007 with Reliance General Insurance  O.p. mentioned that the insurance will be deemed to be continued without  any break to the extent of Rs.4,00,000/- for the insured persons. Therefore the plea of pre-existing disease taken by the o.p. cannot be tenable in the eye of law.

          In view of above it is cleared that the grounds of repudiation letters dated 04.05.2013 and 11.05.2013 issued by o.p. are not applicable in the instant case. The policy was a continuous policy. The complainant initially took the policy from Reliance General Insurance on 24.03.2007 and the same was renewed and thereafter change over was made and the complainant and her family members were under the mediclaim policy of o.p. since 24.03.2011. We have relied upon the document i.e. ENDORSEMENT  dated 24.03.2011 issued by o.p. and these document reveals that the insurance coverage would bed deemed to be continuous without any break to the extent of Rs.4,00,000/- for the insured persons. Therefore the plea taken by o.p. is not at all acceptable. The unjustified reasons for repudiation tantamount to  deficiency in service on the part of the o.p.  Therefore we are in the view that complainant has substantiated her case and as such she is entitled to get relief.

          Hence, ordered.

        that the CC 568/2013 is allowed on contest against o.p. The o.p. is directed to pay Rs.2,02,881/- to the complainant along with compensation of Rs.5,000/- for harassment and mental agony suffered by the complainant and litigation cost of Rs.2,000/- within 30 days from the date of this order i.d., an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.

        Supply certified copy of this order to the parties free of cost.