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

          Complainant by filing this complaint has submitted that he purchased a mediclaim policy of the OP in the year 2009 i.e. on 07-03-2009 which is being continued up to 2012-1013 and during the continuation of his policy and validity of the said policy valid for the period 17-03-2010 to 16-03-2011 complainant was admitted to Fortis Hospital on 22-11-2010 for treatment and was released on 29-11-2010 and he paid the entire bill and other treatment cost.  Thereafter, again he was admitted to the hospital on 25-11-2011 again for treatment and released on 28-01-2011 after treatment medication and medical arrangements.

          For those treatments at the hospital he submitted claim for reimbursement along with entire documentary papers on 21-01-2011 and total claims stood at Rs.1,23,548/- which was duly submitted to the TPA for reimbursement, and the amount for the first claim was Rs.93,204/- and the second claim was Rs.30,344/- but the OP company through their authority Heritage Health TPA Pvt. Ltd. issued a repudiation letter on 28-05-2011 for the first claim and on 22-07-2011 for the second claim stating that “pre-existing disease”.

          Against that complainant submitted appeal before higher authority for the illegal decision of the Heritage Health TPA Pvt. Ltd. and the complainant sent a letter praying for re-consideration of the genuine and bona fide claim of the complainant but they did not respond for which complainant lodged a complaint before the CA&FBP, Govt. of West Bengal for redressal and the OP Company shifted their ground of rejection claiming that claim was made within two years from the of inception.

          Practically to deprive the complainant, in such a manner one after another clause repudiate was cited to the claim without any basis and practically only to harass the complainant they did it and for which the complainant has prayed for redressal and for reimbursement of the same.

          On the other hand OP Insurance Company by filing written statement submitted that complainant has been suffering from pre-existing disease prior to inception of first mediclaim policy commenced on 07-03-2009 and another factor is that complainant suppressed the same and for which the policy which was started on and from 17-03-2009 to 16-03-2010 it was first policy and 2^nd policy.  So, from 17-03-2010 to 16-03-2010 and in between that period he fell ill twice and those period are from 22-11-2010 to 29-11-2010 and 25-01-2011 to 28-01-2011.  So, it is clear that complainant has no legal basis to claim such disbursement against treatment of preexisting disease as per Clause 4.3 of the policy condition and moreover as per 4.1 of the policy clause complainant is not entitled to get any benefit in respect of treatment of any pre-existing disease and for which the claim was repudiated and there was no negligence or deficiency on the part of the OP.

          It is further submitted that as per Clause 4.3, the waiting period for the specified illness/disease/ailments/conditions from the time of inception of the policy, will be two years and the present particular case, the time of inception for the policy is 17-03-2009 and as such two years locking period ends on or about 17-03-2011, whereas the last date of discharge in the case of the complainant was on 28-01-2011.  Thus, complainant falls within the locking period of two years and hence, the insurance company rightly repudiated the claim on the ground of both the exclusion clause 4.1 and 4.3 and further complainant has failed to produce any evidence in support of his prayer for compensation and for which it was repudiated and on the above ground the complainant is not entitled to get any benefit and prayed for dismissal of this case.

Decision with Reasons

Fact remains complainant has admitted that his mediclaim policy started on and from 17-03-2009 and it is also admitted fact that complainant was admitted to hospital for operation twice that is for the period from 22-11-2010 to 29-11-2010 and 25-01-2011 to 28-01-2011 and no doubt those treatment was done long before completion of the locking period of two years from 17-03-2009. 

          It is also proved from the discharge summary of the complainant issued by FORTIS Hospital that complainant suffered from some disease and for which he was operated and it is the second time for recorrection of the same and in this regard the documents were considered by the OP and discharge certificate reveals that patient was admitted for An-Rectal Agenesis – corrected, PSH: Recto-Urethral Fistula (that was done in 1998).  It was a Pena Operation for which the patient was diagnosed for Iliostomy closure by hospital and present illness Recto-Urethral Fistula & Loop Iliostomy with Suprapublic catheter.  From another report of the FORTIS it is found the patient was diagnosed for “Stricture Urethra, Left VUR, Recto-Prostatic Fistula and same are all pre-existing and considering this above discharge certificates OP refused the same.

          After considering the argument of the complainant and the Ld. Lawyer for the OP and also considering the documents it is clear complainant had been suffered from disease i.e. Stricture Urethra, Left VUR, Recto-Prostatic Fistula and prior to that Pena Operation was done in the year 1998 for correction of the disease.  Thereafter, second time this operation was done in two occasions.  So, it is clear that he suppressed all these facts at the time of opening the policy in the year 2009 i.e. 17-03-2009 at the same time it is proved that from the date of inception i.e. 24 months of locking period did not cross but as per conditions of the policy insured is entitled to get benefit of any treatment cost of pre-existing disease after completion of 24 months from the date of opening the policy but in this case we have gathered that 24 months from the inception of the policy did not cross so, as per terms and conditions of the policy as per clause 4.1 and 4.3 no doubt the complainant is not entitled to get any benefit and to that effect the repudiation cannot be stated as illegal or baseless.

          But what we have gathered that first operation i.e. Pena Operation which was done in the year 1998 that operation failed and complainant further suffered from such illness in the year 2010 and first part of 2011 it is impossible for any insured to say that his said disease was continuing since 1998 and up to last part of 2010 when he never suffered from such illness after 1998 and for which he submitted that health condition was OK but he did not disclose that Pena Operation was done in 1998 but as because he is quite ok and his health condition was good but as per medical science Pena Operation may fail and truth is that the complainant was admitted to Fortis Hospital twice in the present case for failure of said Pena Operation.  So, it is no doubt effect of that disease but at the same time we are confirmed that failure of operation after lapse of 12 years cannot be treated as preexisting disease.  But it is sometime unfortunate and for that reason complainant cannot be made accused when he did not suffer from any other disease or the present disease after 1998.  Whatever it may be we have gathered that at the time of opening the policy it was the duty of the complainant to mention that he underwent Pena Operation in 1998 if it would be stated in that case medical check up ought to have been made by the Insurance Company before granting policy so OP failed to get such chance and so such an act on the part of the complainant is no doubt unappreciable as an insured but considering the age of the complainant and also his huge expenditure for such treatment and operation and also considering his continuance of the policy till today since 2009 we are directing the OP to release a sum of Rs.50,000/- as mediclaim against policy or any sum which does not exceeds Rs.50,000/- and if same is found not exceeding the sum assured.  If it is found that Rs.50,000/- is exceeding sum assured in that case the lowest amount which is the sum assured shall be paid.  In fact, this order is being passed to give a social relief to the complainant considering the statutory moral obligation of the Insurance Company to give some relief to the insured when it is found that any past disease is relapsed after 14 years or 20 years.  In the light of the above observation we are allowing relief to the complainant in part applying our social approach and view and invariably we are not telling that OP committed any deficiency or negligence on their part to discharge their duty but OP decided the claim forthwith so no compensation will be granted.

In the result, the case succeeds.

Hence,

Ordered

That the case be and the same is allowed in part on contest with a cost of Rs.5,000/- (Rupees Five thousand only) against the OPs.

          OPs are directed to pay and release a sum of Rs.50,000/- or if that amount exceeds the sum assured in that case the total sum assured but in no way the amount shall exceed Rs.50,000/- and it shall be paid to the complainant within one month from the date of this order but no interest, no compensation is awarded in view of the fact that by applying our social and moral approach and judicial conscience we have allowed this part claim when his policy is being continued for more than 4 years till today. 

          OPs are directed to comply and ought to pay the sum to the complainant within one month from the date of this order otherwise the punitive damages shall be assessed against them.  If it is found that OPs are reluctant to comply this order in that case penal proceeding shall be started against them.