Order-21.
Date-17/07/2015.
Complainant Jay Kumar Sureka by filing this complaint submitted that complainant is a policy holder of Individual Health Insurance Policy under Policy No. 101600/48/12/85000000683 (Policy Year 2012-13) of op no.1 for his self since 21.04.2005 and also for his wife Smt. Manju Sureka vide Policy No. 101600/48/13/85000000703 (Policy Year 2013-14) of the op no.1 and insured paid premium regularly and policy was renewed from time to time.
Op no.2 is the TPA as nominated by op no.1.The insured is the complainant and originally had a sum insured of Rs. 1,50,000/- and cumulative Bonus accrued each year and complainant increased his sum insured by Rs. 50,000/- with effect from 21.04.2011 and further enhanced the sum insured by Rs. 75,000/- with effect from 21.04.2012 subject to policy condition as stated in Clause 4.1, 4.2 and 4.3.
During the relevant policy period 21.04.2012 to 20.04.2013 complainant was admitted to Kottakkalarya Vaidyasala Ayurvedic Hospital & Research Centre, Kottakkal for pain in both knee joints, Hyperthyrodism and irregular heart beat and was admitted on 23.03.2013 and was discharged on 02.04.2013.Complainant was intimated the op no.2 as regards hospitalization and submitted the Hospitalisation Claim Form for reimbursement dated 12.04.2013 along with the discharge summary, prescription with medicine bills and cash memos amounting to Rs. 55,299/- on 17.04.2013 and the said submissions were duly acknowledged by the op no.2 on the same date.But not a single paisa had been paid by the ops without assigning any reason for reason best known to them.Thereafter op no.2 recorded the following information in its website.
Subsequently complainant was further admitted to B.M. Birla Heart Research Centre and was discharged on 02.08.2013 at 04:37 am due to severe heart problem and was registered under Dr. Anil Mishra and was discharged on 12.08.2013 at about 08:06 pm said claim falls under the subsequent policy period from 21.04.2013 to 20.04.2014 and total Hospital Bill was Rs. 1,42,255/- as per Bill No. BIL-13-2767 dated 12.08.2013.
Complainant was again admitted at Care Hospitals, Banjara Hills, Hyderabad on 22.10.2013 at 01:35 pm and was discharged on 30.10.2013 at 12:23 pm due to severe heart problem and was registered under Dr. Narasimhan.Complainant informed the ops through the Hospital Authorities and also through email dated 19.10.2013 and the total hospital bill was Rs. 3,85,383/- as per Bill No. CB1300152467 dated 30.10.2013 issued by the said hospital.
Complainant filed the Claim Form along with documentary evidences in original through Hospital Authorities as per norms and the op no.2 partly paid the claim of Rs. 36,725/- and the balance claim amount to Rs. 3,48,658/- was declined as per information given in the website of the op no.1.Complainant being aggrieved by the action and in action of the ops filed a representation dated 26.06.2014 before the ops requesting to make the payment of the medicalinsurance claim of Rs. 55,299/- pertaining to policy year 21.04.2012 to 20.04.2013.
Further complainant filed a representation dated 26.06.2014 before the ops requesting to make the payment of the medical insurance claim of Rs. 1,94,525/- pertaining to policy year 21.04.2013 to 20.04.2014.But the op no. 2 replied to the aforesaid representation vide letter dated 26.07.2014 under Claim Control No. NI-6-135995 & NI-6-122694 and stated that the complainant is suffering from Heart disease since 2007 and complainant enhanced the sum insured from Rs. 1.5 lakhs to Rs. 2 lakhs in the year 2011-12 and further to Rs. 2,75,000/- from 2012-13 and enhanced sum insured is not applicable in the case of heart diseases prior to enhancement of sum insured and the present claim is restricted to Rs. 1,50,000/- as per clause 4.1 of policy terms and conditions.
Complainant made regular follow up with both the ops and understood that the ops intentionally and deliberately avoided the payment under one pretext or another for reasons best known to them and in the above circumstances, complainant being aggrieved filed this complaint and prayed for redressal and complainant submitted that op no.1 to be directed to pay Rs. 5,59,824/- as alleged claims including interest etc.
On the other hand op by filing written statement submitted that all the allegations as made by the op is false, vexatious and mis-conceived one and op denied the disputes and all the allegations.
In fact in respect of the treatment of complainant for the period from 23.03.2013 to 02.04.2013 and claimed under the policy period from 21.04.2012 to 20.04.2013 no doubt complainant made a claim along with documents but same is not maintainable under the policy condition for the period 2012-13 as per Clause 4.1, 4.3 of Exclusion Clause 1.3.
Subsequent claim of the complainant for this treatment at B.M. Birla Hospital from 02.08.2013 to 12.08.2013 was considered and that claim falls under subsequent policy group from 21.04.2013 to 20.04.2014 as per Clause 4.1 of Mediclaim Policy.So, question of deficiency of service does not arise.
Op no.1 submits that they have issued authorization letter to the complainant for cashless benefit which they utilized at the time of release of patient by getting the benefit of cashless of Rs. 82,500/- as permissible under the law out of total claim of Rs. 1,42,255/- and no doubt balance amount was paid by the party at the time of discharge and no further claim is admissible, so it was not entertained.
As per complainant’s version, he was admitted to Care Hospital, Hyderabad on 22.10.2013 and was discharged on 30.10.2013 due to sever heart problem and accordingly submitted his bill with documents of Rs. 3,85,383/- for payment which was replied by op no.1 by their website claim amount of Rs. 3,70,383/-, bill submitted Rs. 3,85,383/-, payable amount of Rs. 36,725/- as per policy condition (2005-2006) restricted to Rs. 1,50,000/- and not applicable to enhanced policies.
It is further admitted that complainant requested the op on 26.06.2014 to clear up the balance bill so submitted but the op submits that they have replied the complaint reply in details so further reply was not given.It is further submitted that complainant was suffering from heart disease since 2007 and thereafter complainant enhanced the sum insured from Rs. 1,50,000/- to Rs. 2,00,000/- in the year 2011-2012 and thereafter again on 2012-13 enhanced the sum insured and the present claim is not applicable in the case of heart disease prior to enhancement of sum insured and the present claim is restricted to Rs. 1,50,000/- as per clause 4.1 of the policy terms and conditions of mediclaim policy.So, the allegation made by the complainant is fake, so question of deficiency and illegal trade practice does not arise at all.
Further complainant has tried to convince that no claim was settled in respect of the policy period 2013-14.But fact remains that complainant claimed balance amount is Rs. 3,13,750/-, but complainant already received of Rs. 1,94,525/-.So, it is clear that Rs. 1,19,225/- was paid.Further op has submitted that claim is not maintainable in terms of policy conditions and rules frame as mentioned in the written version and everything has paid as per policy condition.So, op denies all allegations of the complainant and prayed for dismissal of this case.
Decision with reasons
On an in depth study of the complaint and written version and also considering the material on records and further relying upon the argument as advanced by the Ld. Lawyers of both the parties, we have gathered that complainant is a bona fide consumer having his Mediclaim policy and in this regard we have gathered that in respect of claim of the complainant Claim Control No. NI-6-53860 op decided the claim for the policy year 2009 – 2010 when sum assured was Rs. 1,50,000/- and amount claimed was Rs. 1,67,541/- and amount was paid Rs. 1,00,700/- and balance amount was not paid as per policy condition and that amount was Rs. 66,841/- (A). (B) in respect of claim No. NI-6-11480 for the policy year 2012-13, sum assured was Rs. 1,50,000/- + Rs. 50,000/- in policy period 2011-12 + subsequent amount claimed was Rs. 55,239/-, but claim was repudiated and total Rs. 2,75,000/-.(C) Claim No. NI-6-122694 and NI-6-135995 for the policy year 2013-14 sum insured was Rs. 1,50,000/- and thereafter it was enhanced for another Rs. 50,000/- and thereafter another Rs. 75,000/- and claimed amount was Rs. Rs. 14,242/- and Rs. 3,85,382/-.But claim was to the extent of Rs. 82,500/- and Rs. 36,725/- and balance part was disallowed as per terms and condition of the policy and also on the ground to enhance rate of sum insured i.e. Rs. 50,000/- and Rs. 75,000/- was not considered in view of the fact that he has his past history of heart disease.So, settlement was done on the basis of policy condition in respect of first sum insured of Rs. 1,50,000/-.
In this regard the Ld. Lawyer for the complainant submitted when sum insured was enhanced and it was accepted, then claim should be considered as per total sum insured for the year 2013-14 when sum insured was Rs. 3 lakhs including bonus.But op did not consider the same.But in this regard the Ld. Lawyer for the op submitted that fact remains the enhanced sum insured that shall be considered including bonus, if no past history of heart ailment is found.But in the present case from the complainant’s own documents, it is clearly noted that complainant had his past history of heart ailment and he had underwent permanent pacemaker transplantation in the year 2007 i.e. prior to policy inception.
But at the time of purchasing the said policy or renewal of the policy, declaration is must in respect of health condition and that was mandatory for him during policy inception.Complainant did not disclose it.But fact remains that insurance contract is based on principle of utmost and good faith and insured has to declare his health status to underwriters for risk assessment and underwriting.
Considering that fact, the op considered the claim of the complainant and insured amount was restricted to Rs. 1,50,000/- and subsequent any amount which has been considered vide Clause 4.1 of the policy and it is further submitted that the condition shall be covered only after 4 years of insurance coverage and as the initial policy was taken for SI of Rs. 1,50,000/- and continued till 2010-2011, the same is only eligible for consideration indemnity limit for management of heart ailment in 2013-2014, since the enhanced SI of Rs. 50,000/- and Rs. 75,000/- respectively during the year 2011-2012 and 2012-2013 had not completed 4 years of continuous renewal when the claim for heart ailment was preferred in the year 2013-14, the claim therefore, being settled the claim with original SI limit of Rs. 1,50,000/- for Rs. 82,500/- as pointed out by the insured against claimed amount of Rs. 1,42,242/- by the hospital no further claim was submitted by the insured against the said hospitalization.
It is also submitted that insured again submitted for reimbursement claim for expenses incurred at Care Hospital from 22.10.2013 to 30.10.2013 for management of his heart ailment once again with a claim amount of Rs. 3,85,383/-, wherein the same was once again settled as per the terms and condition of the policy for Rs. 36,725/- to which the insured has consented and the remaining balance could not be paid due to SI restriction as noted above and his limit under others head policy clause 2.1c, getting exhausted.
So, as per policy condition complainant is entitled to get room rent limit-1 percent of sum insured per day subject to maximum of Rs. 5,000/- and if admitted in IC unit-2 percent of Sum Insured per day subject to maximum of Rs. 10,000/- and overall limit under this head-25 percent of Sum Insured per illness.But Surgeon, Anesthetist Medical Practitioner, Consultants Specials fees, Medicines drugs, Diagnostic Material & X-ray, Dialysis, Chemotherapy, Radiotherapy, cost of Pacemaker, artificial limbs and cost of stent and implant, maximum limit per illness 50 percent of sum insured.
Considering this Clause and also sum insured of Rs. 1,50,000/-, op decided the same in all respect the claim was settled.Thereafter no claim was submitted by the complainant.another factor is that as per Clause 3.0 any one illness will be dimmed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the Hospital/Nursing Home where treatment may have been taken and occurrence of same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy.
Another factor is that in respect of pre-existing disease when the cover incepts for the first time for treatment of pre-existing disease will be covered after four continuous claim free policy years.For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only will be considered and this exclusion will also apply to any complications arising from pre-existing ailment/disease/injuries.Such complications will be considered as a part of the pre-existing health condition or disease.If a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, the policy shall be subject to policy exclusion.
Considering the argument of the Ld. Lawyers of both the parties and particularly after comprehensive study of the policy, it is clear that if the diseases are pre-existing at the time of proposal will be covered after four continuous claim of the complainant.No doubt in this case it is proved that complainant has a past history that means in the year 2007 he was admitted to hospital for implantation of pacemaker and he was a knows case of heart ailment and it was implanted.But thereafter complainant took the policy and enhanced the premium of Rs. 50,000/- for 2010-2011 amount of Rs. 75,000/- for the year 2011-2012.But he did not disclose that he suffered from heart ailment and pacemaker was implanted.
So, considering that fact it is clear that complainant at the time of renewing the policy did not disclose his health status, though he had suffered from heart ailment.No doubt such sort of non disclosure of the health status tantamounts to suppress the heart ailment which has no doubt violated the terms and conditions of the policy and at the time of inception of the case policy at the time of renewal, he did not disclose it for which no doubt for that reason complainant has violated the condition for which he is not entitled to get any benefit.
Another fact is that complainant in respect of claim amount of Rs. 55,239/- total claim was repudiated.But in respect of other claim for policy year 2009-2010, complainant received Rs. 1,00,700/- out of Rs. 1,67,541/- and it was rightly decided considering the sum insured of Rs. 1,50,000/- and in respect of claim of Rs. 1,42,242/- in the policy year 2013-2014, complainant got Rs. 82,500/- and Rs. 36,275/- and total Rs. 1,19,235/- complainant received insured sum by this policy year 2013-2014 and it was decided on the basis of the sum insured of Rs. 1,50,000/- and no doubt op did not consider the enhanced amount of Rs. 50,000/- + Rs. 75,000/- i.e. total of 1,25,000/- on the ground after four year continuous claim during policy year and same shall be considered and that is provision of Clause 4.3.
But it is peculiar that complainant already received Rs. 1,00,700/- against sum insured of Rs. 1,50,000/- in the policy year 2009-2010.Thereafter complainant enhanced Rs. 50,000/- in the year 2011-2012, Rs. 75,000/- in the year 2012-2013.If we considered the Clause 4.3, then we are satisfied that enhancement sum insured of Rs. 50,000/- shall be included with original sum insured of Rs. 1,50,000/- after claim of four year continuous claim during policy year i.e. after 2015 and in respect of enhanced sum insured of Rs. 75,000/-, complainant enhanced it in the year 2012-2013.So, benefit of that sum insured shall be considered after continuous four year claim during policy year i.e. after 2016.
But most interesting factor is that complainant made claim against NI-6-11480 for a sum of Rs. 55,239/- claiming sum insured of Rs. 2,75,000/-.But in no case the enhancement amount of Rs. 50,000/- and Rs. 75,000/- shall be calculated with original sum insured of Rs. 1,50,000/-.
Another factor is that as per Clause-4.13 – Naturopathy, unproven procedure/treatment experiment of alternative medicine/treatment including acupuncture, acupressure, magneto-therapy etc. comes under the purview of Exclusion Clause and at the same time Massage/Streambath/Surodhara & alike Ayurvedic treatment are also excluded from the list.In fact complainant has failed to prove what sort of treatment was given by the said Ayurvedic Research Centre.No name of medicine, nothing is there.
But considering the said medical papers, it is found that only for the Ayurvedic medicines, complainant is entitled to Rs. 6,808/- + Rs. 1,000/- + Rs. 1,000/- + Rs. 715/- but not more than that of Rs. (,523/- in respect of that policy, complainant is entitled to, but no other amount in respect of treatment (Claim No. NI-6-1480) is allowed and no doubt that amount shall be released by the op.
But after proper consideration of the policy condition including the fact of non disclosure of pre-existing disease of heart ailment, placement of pacemaker in the year 2007, complainant renewed the policy and enhanced the sum insured.But fact remains that any subsequent events in all respect, complainant was admitted to Hospital for heart ailment and it is provision of law that if in respect of any treatment of heart, complainant is found treated and subsequently he has spent for the same treatment, then it shall be treated as special complication that is heart ailment and subsequent treatment will be considered as part of pre-existing disease that is hear ailment and subsequent treatment by implanting pacemaker.So, it is clear that since 2007, complainant has been suffering from acute heart ailment for which the pacemaker was implanted but that was suppressed.
Thereafter complainant was hospitalized for heart ailment in the year 2009-2010, 2012-2013, 2013-2014 and complainant prayed for treatment cost.Even then the ops considered the claim of the complainant and fixing original sum insured of Rs. 1,50,000/- and in the year 2013-2014, op paid Rs. 1,19,225/- and in the year 2009-2010 paid Rs. 1,00,700/- out of claim of Rs. 67,541/- and in reality op discharged their duty showed their mercy and also showed all sorts of moral and social responsibility as a corporate establishment.But even then complainant suppressed his previous heart ailment placement of pacemaker etc. and continued and renewed the policy enhanced the sum insured and tried to grab more money.
Truth is that in the present complaint many things are in details noted.But peculiarity is that this policy condition which are being ventilated by the complainant’s Ld. Lawyer.But vital fact is not ventilated in the complaint that is vital for which it must be disclosed by the complainant that he has not disclosed that he has been suffering continuous four year heart ailment and his condition was severe for which pacemaker was implanted in the year 2007, that was suppressed and considering that fact we are convinced that this complainant did not act as an honest only for the purpose of grabbing more money, then this complaint was filed and truth is that op discharged their duties and responsibilities well with their moral sense and activities.They can easily be repudiated the claims.But even then op did not repay and he got some benefit considering the fact that he is being admitted again and again to hospital for his heart treatment.
Last but not least we are ventilating for the details for which the complainant was admitted to hospital for the period 03.03.2013 to 02.04.2013, complainant was admitted to Ayurvedic Hospital at Kottakkalarya Vaidyasala Ayurvedic Hospital & Research Centre, Kottakkal with pain in both knees and also suffered heart problem.Thereafter in the period ..... to 12.08.2013, complainant was admitted to B. Hospital with severe heart problem.Further she was admitted to Care Hospital, Hyderabad due to severe heart problem and was treated from 22.10.2010 to 30.10.2010 and against three treatment, complainant submitted medical bill.In fact this bill should be rejected by the op.But even then op considering the customer payment of premium huge amount was released out of the claim.But if op did not allow this application in that case, complainant shall not have to get the same.But anyhow in the particular case no doubt op showed their social responsibility, moral values as Insurance Company, insurance is a social legislation and that was followed in this case and payment as made by the op is social and as per contract and fact remains that this Forum cannot go beyond the terms and conditions of the policy and there is no scope of this to show any equity or any exception.
But even then we have gathered that the entire complaint is nothing but a greedy complainant as consumer.In the light of the above observation, we find there is/was no deficiency or negligence for unfair part on the part of the ops for which this complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest without any cost against the ops.
