Order No.                 .

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this compliant has sub mitted that he is a policy holder of OP1 being policy no.10300/48/10/8500004915 which is known as hospitalization benefit policy.

          On 02-02-2012 complainant was suddenly hospitalized as per advice of Dr. Indrajit Roy, MS MCH for surgical operation as he was suffering from lumber spondylosis and was admitted to Nightingle Hospital, Kolkata for the said operation purpose and before undergoing said surgical operation few required medical tests were conducted wherein it was found that the complainant was having high diabetes for which after thorough consultation it was decided by the doctor that the said operation may be postponed for the time being as it was not be possible to undergo the brought down to such level that the said operation may take place.  As a consequence of which the complainant was discharged from the hospital on 04-02-2012 but complainant was undergone regular treatment for diabetes and lumber spondylosis and required surgical operation.  On 29-12-2012 complainant through E-mail informed about his claim to the OP2 in respect of the said mediclaim policy and requested them to provide claim through E-mail and subsequently filed this claim in due manner under the said medical insurance policy after the receipt of claim form on 09-03-2012.  Complainant submitted his final claim on 31-03-2012 wherein along with duly filled claim form he sent all the relevant original documents relating to the said policy.  But even after repeated requests made by the complainant OP did not take any step but subsequently vide letter dated 22-05-2012 and 13-06-2012 and to submit all past policy copies, provide other documents to show how long he had been suffering from diabetes and details of his previous treatment duly certified by treating doctors and indoor case papers for further scrutiny to know and determine that what was his health condition at the time of commencing the said policy.  Against the complainant sent a letter dated 19-06-2012 clarified his position and submission regarding above mentioned document.  Thereafter, waiting for  long time on 13-03-2013 sent a demand notice which was received by the OP on 14-03-2013 when complainant received a letter dated 06-03-2013 by the OP informed that his claim was repudiated as per Clause 4.10 on the ground expenses incurred primarily for evaluation/diagnosis purpose not followed by active treatment during hospitalization.

          Practically complainant on receipt of the same was astonished and again filed a prayer for review on 06-04-2013 challenging the wrongful decision and                         of claim and prayed for payment of the same but that was not considered and by that way complainant has been harassed at this stage was for negligent and deficient manner of service this complaint is filed for relief.

          On the other hand, OP by filing written version submitted the present complaint is not maintainable in view of the fact laches, deficiency, negligency on the part of the OP has not been proved further it is submitted that OP asked the complainant by their letter dated 22-05-2012 and 13-06-2012 to submit all past policy copies and other document regarding diabetes prior to that date for further scrutiny and determine the complainant instead of honouring the OPs demand for relevant medical documents made allegation alleging them that already deposit document already to the OP for mediclaim and prays for settling the claim.  But complainant to pressurize the OP by writing a letter to 19-06-2012 he already submitted a document to the OP for mediclaim but actually as per requirement of the OP complainant did not supply it and filed to submit it so OP failed to consider the application for absence of relevant documents asked by the OP.  Further OP submitted that OPs already repudiated the claim on 06-03-2012 because no active treatment was taken and operation was not truth due to uncontrolled sugar.  So complainant has failed to comply the policy condition so the question of mediclaim compensation is does not arise at all and prayed for dismissal of the case.

Decision with Reasons

On proper consideration of the entire complaint including written version and the documents as submitted by the complainant it is clear that complainant was aged about 64 years on the date of his admission at Nightingle Hospital on 02-02-2012 and he was discharged on 04-02-2012 but he was admitted for diagnosis of lumber spondylosis.  So, operation was needed and required but it could not be done as due to uncontrolled Diabetes Mellitus so in between 02-02-2012 to 04-02-2012 when he was in the Nightingle Hospital his course for treatment is conservative and no doubt prior to that some investigation was done but anyhow as per said discharge summary it is clear that on admission no active treatment was done.  Moreover, Ld. Lawyer for OP submitted that uncontrolled diabetes means the patient had been suffering from several years for diabetes and the present stage is uncontrolled all on a sudden uncontrolled diabetes cannot be detected in any patient and so, it is clear that complainant suppressed his suffering from diabetes at the time of opening the present policy because the present policy was started on and from 03-02-2010 and complainant was admitted to the hospital for uncontrolled diabetes mellitus for operation that is within two years from the date of inception of the policy i.e. on 03-02-2010.  So, as per policy condition the complainant was not treated for which he was admitted and operation was not done.  So, as per policy 4.10 expenses incurred primarily for evaluation/diagnosis purpose not followed by active treatment during hospitalization cannot be given and comply this clause complainant’s claim was repudiated.

          On the other hand, complainant himself and his Ld. Lawyer submitted that there is no such document to show that complainant was suffering from any type of diabetes prior to 02-02-2012 and for the first time it was detected that it was uncontrolled diabetes mellitus.  So, the clause 4.10 is not applicable and further submitted that though operation was not done but conservative treatment was done by hospitalization but in this regard Ld. Lawyer for the OP submitted that conservative treatment is not applicable as per policy condition for conservative treatment the complainant may get such treatment in house not at any Nursing Home or Private Hospital.

          It was further submitted that uncontrolled diabetes means the diabetes that has not being treating for all the years together or is being technically treated causing blood sugar level to raise in the patient but complainant suppressed this factor of pre-existing disease of uncontrolled diabetes and in case of uncontrolled diabetes constantly high blood glucose level are increased day by day and patient can develop several problems like seizure, fall into coma and some other problems.  So, considering the pre-existing disease of uncontrolled diabetes as opined by the doctor for which operation was refused in the present case and practically no treatment was done for which the complainant claim was repudiated and that was as per clause of the policy.

          Considering the argument of the Ld. Lawyer for the OP and also considering the history of uncontrolled diabetes as pointed out by the doctor after admission of the present hospital is no doubt a cause for repudiation of the claim of the complainant but we must have to satisfy ourselves whether uncontrolled diabetes may be found suddenly after any ailment or there no nexus with the continuous suffering from diabetes with uncontrolled diabetes and in this regard we have gone through the medical authority’s book regarding uncontrolled diabetes and on study of the same it is found that uncontrolled diabetes is caused when a patient has been suffering from diabetes but he is not been treated at all or he is not being technically treated causing blood sugar level to raise in the patient and if any patient does not keep any proper watch day to day in his suffering from diabetes in that case the position of the diabetes shall be uncontrolled diabetes.  But fact remains after studying that chapter it is found that uncontrolled diabetes is not caused in respect of any patient suddenly but there must be a past history of diabetes which needed regular check up but if it is not checked up and proper treatment is not made in that case uncontrolled diabetes are found in a body of a patient and when the status of the patient in respect of his diabetes is uncontrolled diabetes in that case no treatment respond to such situation and it is further found from said book of authority of medicine that there is only high blood glucose level is always seen and uncontrolled diabetes is the last stage of continuous period of suffering of  diabetes.  Considering the above authority of medical science regarding definition of uncontrolled diabetes we are confirmed that complainant had been suffering from diabetes for many years and he had not been properly treated and technically treated for which the blood sugar level was arisen in the patient body system at a highest stage and for which it was detected as uncontrolled diabetes and it is also found from that definition that if a patient does not take proper medicine to check the diabetes in that case in all cases uncontrolled diabetes shall be found and in this case no doubt uncontrolled diabetes was detected in respect of the patient during checking up and inspection and the present patient complainant failed to seek treatment or did not adhere to treatment regiment for uncontrolled diabetes which is a serious medical issue and for which there was complete risk factors and for that reason doctor refused to operate.  So, considering all the above facts it is clear that complainant had been suffering from diabetes for past two or three years and that was not properly treated or controlled and ultimately the present stage of uncontrolled diabetes was detected and as per medical science uncontrolled diabetes means a person who has been suffering from uncontrolled diabetes having his past continuous history of diabetes without any medical treatment for which at last stage patient is suffering from uncontrolled diabetes if this definition is accepted as authority of the medical science then after applying that principle of medical science in the present case it is clear complainant had been suffering from diabetes for many years and there was no proper check up or treatment for which ultimately it was detected that he has been suffering from uncontrolled diabetes on the date of admission to hospital for operation.  So, it is confirmed that complainant suppressed his previous diabetes and it is also proved that uncontrolled diabetes cannot be occurred suddenly and there is or was no medical theory to that effect that uncontrolled diabetes may be caused suddenly without any past history by suffering from diabetes.  In view of the above findings we are convinced to hold that no doubt OP rejected the claim of the complainant on the above ground as the complainant suppressed his past history of diabetes which has caused the present situation of the complainant in respect of his sufferings uncontrolled diabetes.  

          So, as per terms and condition complainant did not disclose his disease the pre-existing in nature.  Further as per policy condition it is the duty of the complainant to disclose.  So, complainant is not entitled any claim as made.       

          Moreover, OP again and again reported to the complainant to provide all past policy copies and if it would be filed by the complainant in that case there was chance to get some relief if it would be found that he has continued medical policy for continuous four years and in that case complainant ought to have get claim amount of 25 to 50% of the total claim.  But that has not been proved.  Further OP reported the complainant to file certificate of the treating doctor about the case history of present uncontrolled diabetes but that has not been done.  So, considering all the above facts of repudiation as made by the OP is not found unjustified, illegal but truth is that complainant did not supply other document and no such document is produced by the complainant before this Forum to show that the doctor who treated the complainant has certified that uncontrolled diabetes may be caused suddenly without any past continuous history of suffering from diabetes and considering that fact it is clear that complainant’s claim which has been repudiated is not anyway unjustified.  Anyhow, Ld. Lawyer for the complainant vociferously argued that complainant was harassed but in this regard it is to be mentioned that definition harassment is very wide in nature but harassment only can be proved if it is found that any person has received any relief at belated stage without any explanation or on the ground of delay but in this case OP repudiated it.  Repudiation is apparently found as per policy condition then from very inception complainant is not entitled to get relief though may be complainant at later stage received the seal but truth is that prior to that if complainant was asked to file certain documents but truth is that complainant did not submit it but he gave his own opinion about the uncontrolled diabetes but not about his past disease etc. but such explanation of the complainant cannot be accepted as an authoritative expression of an experienced doctor.

          Considering all the above facts and circumstances, we are convinced to hold that OP has failed to prove by any cogent evidence the negligence or deficiency on the part of the OP or repudiation of the present claim as illegal.

          But even then we are giving a chance to the complainant to file all those documents as required by the OP within one month from the date of this order and OP shall have to reconsider the prayer of the complainant and invariably complainant shall have to submit a report of any Board of Doctors expertise in respect of diabetes and also a report of such doctors that uncontrolled diabetes may be caused suddenly without any past history of continuous suffering from diabetes if such certificate is filed by the complainant after collecting it from an expertise doctor of any medical board or college to the OP.  OP shall have to consider his claim to give some relief to the present senior citizen so that his grievance may be redressed by the OP Insurance company and in such findings we are dismissing the complaint.

Hence,

Ordered

That the case be and the same is dismissed against the OP on contest but without any cost.

          OP is directed to consider his claim again if complainant would be able to produce any opinion of Board of Doctors expertise in the field of diabetes treatment to the effect that a patient without any past history of any sort of suffering from diabetes may be take up uncontrolled diabetes and if such certificate is found filed by the complainant to the OP in that case OP shall have to reconsider the claim of the complainant otherwise not.  So, complainant is given a liberty to file such certificate as per observation of the Forum to the OP and on receipt of the same OP shall reconsider his claim to give certain relief for its effective operation was not done first.