This case has arisen out of an application U/s 35 of the Consumer Protection Act, 2019.
The case of the complainant is that she is an educated women and her husband is a retired teacher, in the year 2018 she took a health policy jointly in her name with her daughter, namely, Rituparna Choudhury from O.P/Insurance Company, renewed on 24.05.2021 vide Policy No:-51300234212800000009, valid till 27.02.2022, sum insured Rs.2,00,000/-.
That in the year 2021 she was diagnosed with Post Menopausal per vagina bleeding and was treated at Apollo, Ruby General Hospital etc but to no avail. On the advice of Dr. Sanjay Kumar Biswas and Dr. Tirtha Pratim Purkait she was admitted to Ruby General Hospital on 01.11.2021 where operation was done on the same day and discharged on 04.11.2021.
That after admission to hospital her husband informed O.Ps who sent an employee, namely, Biplab Paul to the hospital on the night of operation who misbehaved with her. After discharge on returning home she filed claim form with the O.P/Insurance Company on 20.11.2021 and O.Ps took original documents from her but did not pay claim even after lapse of many days, later sent a letter to her on 31.01.2022 and repudiated her claim on the ground of pre existing disease since 2018.
Hence, the petitioner lodged complaint with prayer to direct the O.Ps to pay Rs.1,24,102/- towards medical expenses with interest, for damages and harassment of Rs.1,00,000/- & litigation cost of Rs.20,000/-.
O.Ps contested the case by filing W.V stating that the complainant was issued a Health Insurance Policy under Plan, namely, “New India Floater Mediclaim Policy” by O.P/Insurance Company bearing current Policy No:-51300234212800000009 w.e.f 28.05.2021 till 27.05.2022 providing policy coverage to complainant and her daughter RituParna Choudhury for a sum insured Rs.2,00,000/-, subjected to policy terms and conditions. The O.P/Insurance Company received a claim Form from the complainant where she claimed Rs.2,00,000/- for her treatment and stated that she was suffering from the disease of Post Menopausal per vagina bleeding and her treatment was done in Ruby General Hospital and she was also treated by various Doctors for the same disease in different places before treating by the Doctor(s) of Ruby General Hospital. An investigation was triggered by the O.P/Insurance Company and raised query to medical documents and Doctor’s prescriptions, which show that she had been suffering for a long time for pre-existing disease before 28.05.2018 i.e prior the issuing first mediclaim policy by O.P/Insurance Company. Since the complainant purchased the policy from the O.P suppressing her pre-existing disease to get illegal benefit, as such she has violated the terms and condition of the policy & her claim was repudiated under clause 4.1 Permanent Exclusion :Condition caused by pre-existing disease. O.Ps pray for dismissal of the case.
Points for consideration are:-
- Whether there was any deficiency in service on the part of the O.Ps which gives rise cause of action to file the complaint and the complainant is entitled to get the claim?
D e c i s i o n w i t h r e a s o n s
Admittedly, in the year 2018 the complainant took/purchased a Health Insurance Policy under Plan, namely, New India Floater Mediclaim Policy from O.P/Insurance Company covering herself (hereinafter referred to as “insured/policy holder”) & her daughter, namely, Rituparna Choudhury for a sum insured Rs.2,00,000/-, subjected to policy terms & conditions, vide Policy No:-51300234182800000010 valid from 28.05.2018 to 27.05.2019, renewed vide policy No:-51300234182800000011 valid from 28.05.2019 to 27.05.2020, renewed vide Policy No:-51300234182800000013 valid from 28.05.2020 to 27.05.2021 & lastly renewed vide Policy No:-51300234212800000009 valid from 28.05.2021 to 27.05.2022.
It is also admitted that the complainant was diagnosed with the disease, namely, “ Post Menopausal per vagina bleeding” & on the advice of Doctor admitted to Ruby General Hospital Ltd on 01.11.2021 and her operation was done on the same day and thereafter discharged from the hospital on 04.11.2021. Discharge summary and certificate depicts name of Consultant: Dr. Sanjay Kumar Biswas, Additional Consultant : Dr. Tirtha Pratim Purkait & patient Jaya Choudhury was also seen by : Dr. Suchismita Haldar & operation was done by Surgeon Dr. Sanjay Kumar Biswas. Discharge Summary depicts name of customer: Heritage Health Services.
O.P/Insurance Company admits that the hospital Authority claimed the amount for treatment cost for the patient/Jaya Choudhury, on behalf of the patient as per norms of medical policy and the column “request for cashless hospitalization for health insurance, part-c (revised form) filled by the patient/insured-may be requested by insured/hospital authority.
Question No:-20 replied in affirmative that O.Ps have prepared it according to IRDA guideline.
Question No:-17 replied by O.P/Insurance Company that Dr. Sanjay Kumar Biswas has not signed in hospital declaration & signatory, his qualification and designation has not known-as it is a function of hospital authority where she was treated.
Question No:-18 replied in affirmative that signature of patient/representative in the declaration form was taken.
Undisputedly on receipt of request for cashless hospitalization on 01.11.2021, vide claim No/CCN-HH242204807, Heritage Health Insurance TPA Pvt. Ltd, engaged by O.P/Insurance Company, who raised query: provide all previous treatment documents regarding Polypectomy in 2018 along with Doctor’s prescription & detail Rx sheet on 01.11.2021, submitted with TVS report on 03.11.2021 and looking the PID (28.05.2018) & pre-existing nature of the disease (Post Menopausal bleeding since 2018) we (TPA) regret our inability to sanction cashless. May submit all for reimbursement.
General Information regarding previous treatment document with ICP (regarding query) shows that preauthorization/INT received on 01.11.2021 & Biplab Paul, Investigator appointed by TPA visited the hospital and collected data from the authorized signatory of the hospital, medical related-Chief complaint C/o bleeding P/v with H/o Polypectomy done in 2018 (Genesis Hospital-Dr. Mahua Bhattacharjee).
H/o Post Menopausal B/L in 2018 & again B/L PV in Aug, 2021 (Dr. Tanmoy Roy-Dr. Mahua Bhattacharjee-Dr. Sanjay Biswas).
Final opinion of the Investigator about the case: This 56 Yrs female was admitted with c/o bleeding P/v with H/o Polypectomy done in 2018 (Genesis Hospital-Dr. Mahua Bhattacharjee). H/o Post Manoposal B/L in 2018 & again B/L P/V started on August, 2021- consult with local physician then consult with Dr. Mahua Bhattacharjee then consult with Dr. Sanjay Kumar Biswas H/O present illness :P1+1, LCB-3 Yrs, VD ** previous discharge summary did not given-patient’s daughter, last 10 Yrs treatment by Dr. T.P.Purkait, held the claim non-admissible and rejected as per clause 4.1.
Accordingly, O.P.No-1 by letter dated 31 Jan, 2022 informed her that “we are in receipt of original claim file sent to us from Heritage TPA repudiating your claim stating the reason that the nature of the disease is pre-existing (Post Menopausal bleeding since 2018) and hence as per policy terms and conditions the claim is not admissible under Clause No:-4.1.
O.P/Insurance Company replied to Question No:-5 of complainant’s questionary that normally a fit person can purchase any medical policy without suppressing any previous disease. Jaya choudhury was shown normally a fit as per medical word but she suppressed her secret disease at the time of purchasing insurance policy from O.P/Insurance Company.
The specific case & evidence of O.P/Insurance Company is that since the complainant purchased said Health Insurance Policy from O.P/Insurance Company to have been suppressed her pre-existing disease, she has violated the terms & conditions of the policy.
Under above facts and discussion, we are of the considered view that there was/is no deficiency of service on the part of O.P/Insurance Company or Branch Manager, Raiganj Branch of O.P/Insurance Company, in not paying complainant’s claim or in repudiating her claim in terms of Permanent Exclusion clause No:4.1 of the terms & condition of the policy schedule. Consequently, the complainant is not entitled to get relief as prayed for.
In the result the case fails.
Hence, it is
O R D E R E D
that the C.C-19/2022 be and the same is dismissed on contest against the O.Ps but without any cost.
Let a copy of this order be given to the parties free of cost.
