FINAL ORDER/JUDGEMENT
Smt. SAHANA AHMED BASU, Member,
The case of the Complainant, in short, is that, the Complainant purchased a health insurance policy having no. 104200501810012760 from the OPs 1 & 2 and the same was valid for the period from 15.01.2019 to 14.01.2020. On 04.07.2019 the Complainant was admitted tohospital for the treatment of Urinary Tract Infection, Hypovitaminosisd Allergic Skin Lesion and was discharged on 08.07.2019. After discharge from the hospital the Complainant filed reimbursement claim to the OPs for Rs.57,272/-along with Claim Form, all bills, treatment records including prescription, admission form, Discharge Certificates and other relevant papers which was duly received by the OP3 on 23.07.2019 and the claim intimation was docketed being ID no. 2028727. Thereafter on 25.07.20219 the OP3 requested the Complainant to submit the details from attending doctor, indoor case papers and positive investigation and the Complainant had submitted all documents on 14.08.2019. Again on 20.08.2019 the Complainant was further asked to submit first consultation paper which detected UTI first. In reply vide letter 27.08.2019 the Complainant informed the OP3 that she was not consulted by any doctor and referred the doctor’s certificate dated 09.08.2019 in which it was clearly mentioned that past one month before 26.06.2019 the Complainant was suffering from recurrent UTI and USG report and X-Ray report were also enclosed with the said letter. Despite receiving the said letter the OP3 did nothing and under compulsion the Complainant requested the OP3 vide letter dated 13.09.2019 to settle the claim. But the OPs took no fruitful steps in the matter of settlement of the claim. Being disgusted and saturated by the act of the OPs the Complainant sent an E-mail dated 17.10.2019 to the OPs and called them to disburse claim amount of Rs,57,272/- without any further delay. Upon receiving the above referred e-mail the OP2 served one letter under reference no. 104200/claim/pkb/pb: as : skl dated 27.09.2019 and by such letter repudiate the claim of the Complainant showing that the subject claim is not covered as per Clause 4.1 and 4.3 of the policy. Receiving the said letter the Complainant met the higher officials of the OPs. But returned with empty hands. Finding no other alternative the Complainant filed this case for relief/reliefs.
OPs 1 & 2 contested the case by filing W.V. contending inter alia that the instant complaint is baseless, suppression of facts, false, barred by limitation and is barred by mis-joinder and non-joinder of the necessary party.. The case of the OPs 1 & 2 is that, the Complainant took a Mediclaim Policy being No. 104200501810012760 for the period from 15.01.2019. to 14.01.2020 for the sim assured Rs.3,00,000/- for which total amount of premium paid Rs.4389/- . On 23.07.2019 The Complainant was filed a claim to the OP3 wherein facts revealed that Complainant was hospitalized on 04.07.2019 and discharged on 09.07.2019 wherein mentioned in the ‘Discharge Summary’ that diagnosis for ‘Urinary Tract Infection’, ‘Hypovitaminosis D’ and ‘Allergic Skin Lesion’ and after required treatment was given the Complainant is hemodynamically stable & fit for discharge. After scrutinize all the medical papers and documents submitted by the Complainant it was decided by the OP3 that the case is not fit for payable medical reimbursement and sent a repudiation letter to the Complainant on 20.09.2019 wherein the reason for repudiation is mentioned. Ops 1 & 2 also sent a letter dated 27.09.2019to the Complainant informing that TPA and Insurer are not in apposition to settle the claim as per terms and condition of the policy. Hence there is no deficiency in service on the part of the OPs 1 & 2.
Upon service of notice OP3 did not appear before the Commission and no WV is filed on behalf of them within stipulated period. Thus the case has proceeded ex parte against the OP3.
We have gone thoroughly evidence adduced by the parties including documents on record and gave careful consideration to the arguments advanced by the Ld. Lawyers for the parties.
The admitted fact is that the Complainant took a Mediclaim Policy being No. 104200501810012760from the OPs 1 & 2 for the period from 15.01.2019. to 14.01.2020 for the sum assured Rs.3,00,000/- for which total amount of premium paid Rs.4389/-. Fact also remains that Complainant was hospitalized on 04.07.2019 and discharged on 09.07.2019and a claim of Rs.57,272/- was filed by the Complainant to the OP3 and the same was repudiated by the OPs as per Clause No. 4.1 and 4.3.(ii).
On perusal of the record it is found that the Complainant went to Dr. Raktimava Sarkar for consultationon 26/06/2019with severe excruciating pain in lower abdomen for last one month andthe Complainant was treated by admitting in the Spandan Hospital for the disease of Urinary TractInfection, Hypovitaminosis D, Allergic Skin Lesion under the same Doctor from 04.07.2019 to 09.07.2019 as mentioned in theDischarge Summary of the said Hospital.Photocopy of the Claim Form goes to show that an amount of Rs.57,272/-was claimed by the Complainantfor reimbursement to the OP3vide Claim Intimation ID. 2028727 on 23/07/2019.Annexure ‘C’ adduced by the OPs 1 & 2 reveals that the OP3 repudiated the Claim of the Complainant vide Repudiation Letter dated 20/09/2019 and intimated thethe OPs 1 &2 Reason for Repudiation is that:
The Discharge summary, Indoor case papers submitted / retrieved in the documents indicate that 33 years old female admitted with complaints of abdominal pain for 2 weeks, relevant investigations were done & diagnosed to have ‘Urinary tract infection, Hypovitaminosis D & Allergic Skin lesion’ and treated conservatively. According to available documents patient has history of recurrent UTI, USG dated 28/06/2019 revealed bulky uterus with multiple intramural myomas, Polycysticovaries, significant post void residual urine. Current claim reported in only 6 months old policy with inception since 15/01/2019 while Date of admission on 04/07/2019. So evidently, in this case chronicity / long standing nature of ailments along with definite cause of abdominal pain could not be evaluated where pre-existing clause & 2 years waiting period has not been waved off. Hence the claim is being denied under clause no. 4.1 , 4.3 ii of the policy.
On receipt of the abovementioned recommendation from the OP3the claim of the Complainant repudiated bythe OPs 1 & 2 d vide letter dated 27/09/2019 informing that:
Since the subject claim is not covered as per clause No. 4.1 , 4.3 ii of policy conditions, so we have no other alternative but to repudiate the claim.
Ld. Advocate for the Complainant alleged that the claim of the Complainant was illegally repudiated by the OPs. In this regard we can have a look on the Clause 4.1&4.3(ii) of the Policy Conditions:
Policy Clause:
4.1:All pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from pre-existing ailment/disease/injuries/ will be considered as a part of the pre existing health condition or disease.
4.3 (ii): Two years waiting period a. Cataract k. pilondialsinus b. Benign prostatic hypertrophy I. Gout and Rheumatism c. Hernia m. Hypertension and related complications d. Hydrocele n. Diabetes and related complications e. Congenital internal disease o. Calculas disease f. Fissure/Fistula in anus p. Surgery of gall bladder and bile duct excluding malignancy g. Piles (Hamorrhoids) q. Surgery of genito-urinary system excluding malignancy h. Sinusitis and related dosorders r. Surgery for prolapsed intervertebral disc unless arising from accident i. Polycystic ovarian disease s. Surgery of varicose vein j. Non-infective arthritis t. Hysterectomy.
We have travelled over the documents placed on records by the parties and observed that there is no whisper of pre-existing disease/diseases in the Discharge Summary issued by the said Hospital.It is also observed by us that the treating Doctor, namely Dr. Raktimava Sarkar,certified with explanation regarding the disease UTI on 09/08/2019 that the Complainant was suffering from Recurrent UTI last one month before 26/06/2019. Photocopy of the letter dated 27/08/2019 showing that in connection to submit first consultation paper prior to 26/06/2019 the Complainant replied to the OP3 that, before 26/06/2019 she has not consulted any doctor.Moreover, The Complainant had not any type of surgery. Therefore, we did not find any logic of exercising the Clause 4.1 & 4.3 (ii) of the policy by the OPs. It appears as unfair trade practice on the part of the OPs.
Ld. Advocate for the OPs 1 & 2 argued that OP3 has recommended for repudiation of the claim after scrutinizing the claim files as per opinion of their panel doctor and claim adjudication department.In this regard we may refer the Question No. 26 & 27 of the Complainant and Reply of the OPs 1 & 2 for the same:
Q26. Before taking decision of repudiating the claim of the Complainant, did you obtain your Doctor’s opinion and to that effect any statements are made either in the written version or in the Affidavit on Evidence about such Doctor’s opinion?
Answer: The Opposite Parties authorized TPA’s panel doctors examine the documents as a normal practice.
Q27. If the opinion of your Doctor was obtained by you, in that case have you filed such opinion in this case ?
Answer: Opposite Parties authorized TPA was intimated to the complainant vide their letter dated 20.09.2019.
From the abovementioned Reply of the OP it is clear that they are not equipped enough with the written opinion of the panel doctors of OP3. Not only that the OP3 did not attach any opinion of the said panel doctors in a written form with their letter dated 20/09/2019. In this regard it is our observation that OP3 is a third party and has not connected with the Complainant directly. OPs 1 & 2 receive premiums from their Consumers. Therefore as a service provider they are bound to be transparent to the Complainant.
To establish the case Ld. Advocate for the Complainant relied upon the Judgement passed by the Hon’ble SCDRC as repoted in iv (2002) CPJ (Del) wherein Hon’ble SCDRC held that:
It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim coverage meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer’s primary liability.
Hon’ble SCDRC also held that:
Further, it is well settled law that the Insurance Company before issuing the policy should have examined the person through medical tests in order to check whether the person is suffering from any pre existing diseases.
Ld. Advocate for the Complainant relied upon another Judgement passed by the Hon’ble NCDRC reported in 2016 (4) CPR 34 NC wherein the Hon’ble NCDRC observed that it is the bounded duty of the Insurance Company to have verified information in Proposal Form by obtaining suitable expert.
In view of the above , we are opined that OPs 1 & 2 have not taken any expert opinion either at the time of issuing policy or at the time of repudiation of the said claim and they were not justified in repudiating the claim of the Complainant on the basis of Pre-Existing Disease. Ld. Advocate for the OPs 1 & 2 has relied upon the matter of Suresh BaghrechaVs. Golden Multi Services Club Ltd. &Anr reported in II (2021) CPJ 366 (NC) which have no relevance with this instant case.
Based on the discussion above the instant Complaint is allowed on contest against the OPs 1 & 2 and dismissed on exparte against the OP3 with following directions:
- OPs 1 & 2 are jointly and severally directed to reimburse the amount of Rs.57,272/- to the complainant.
- OPs 1 & 2 are also directed to pay an amount of Rs.10,000/- to the complainant as litigation cost.
- Further, OPs 1 7 2 are jointly and s everally directed to pay an amount of Rs. 25,000/- to the Complainant as compensation for harassment and mental agony.
- Abovementioned directions should be complied within 45 days from the date of this order failing which the reimbursement amount shall attract the interest @ 12% p.a.
Liberty be given to the Complainant to put the case in execution if the OPs transgress this order.
