PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding the deficiency in service on the part of Opposite Parties as they have repudiated the legitimate insurance claim of the Complainant on frivolous ground as alleged by the Complainant.
2) The facts of the complaint as mentioned by the Complainant are that the Opposite Party No.1 is the Insurance Company and Opposite Party No.2 is Agent of Opposite Party No.1. The Complainant has taken a Mediclaim Policy No.121501/48/06/924 valid form 03/09/05 to 02/09/06.
The Complainant is holder of mediclaim policy issued by the Opposite Party No.1 since, 02/08/85. The first mediclaim policy was incepted from 02/08/085. This mediclaim policy was renewed from time to time since 1985 in continuity without any break till Feb. 2006 i.e. till the Complainant made his hospitalization claim. During this period, the Complainant has not raised any claim. Policy No.924 (in short last digits) was in force from 0309/05 to 02/09/06.
3) The Complainant has further stated that the policy was renewed form time to time. When the policy incepted the Complainant was not suffering form any ailment, no hypertension and, no heart ailment. However, hypertension was detected in the year 2003 and diabetes was detected in the year 2004 and he was under treatment of Dr. A.R. Ghamade, a Consultant Physician and Chest Specialist. In Jan., 2006, ECG showed some abnormality. The Complainant was advised to approach Dr. Satyawan Sharma of the Bombay Hospital. He approached Dr. Sharma on 09/01/06. The Complainant had no occasion to inform Dr. Sharma that he is suffering from Hypertension for more than 20 years and also he is suffering form diabetes for more than 6-8 years. Dr. Sharma arranged angiography of the Complainant on 14/01/06. Mean time on Eco cardiogram was taken in Hinduja Hospital on 10/01/06.
4) The Complainant has further stated that he was having a cashless policy. But Complainant’s signature was not obtained on the preauthorization form. On 12/01/06 the Complainant was told that Opposite Party No.2 is not extending the cashless facility. Angiography was fixed on 14/01/06. Angiography was done by Dr. Sharma on 14/01/06. After that Dr. Sharma suggested bye pass surgery CABG – which was done by Dr. Aniruddha Trivedi on 02/02/06. The Complainant was discharged on 14/02/06. Therefore, he lodged a claim for Rs.2,36,000/- vide his application dtd.01/03/06. However, the Opposite Party No.2 repudiated the claim vide its letter dtd.22/03/06 stating that as per the documents received by the Opposite Parties, the insured has history of Hypertension since last 20 years and it is a proximate cause of the Unstable Angina. Hence, as Hypertension is pre-existing condition before inception of the policy this claim stands non payable under clause 4-1 of the mediclaim policy.
5) The Complainant has further stated that Bombay Hospital, through Dr. Sharma had submitted pre-authorization form to the Opposite Party No.2 singed by the secretary of Dr. Sharma between 09/01/06 to 12/01/06. In this preauthorization form, the secretary of Dr. Sharma, on her own accord, or presumably as per instructions of Dr. Sharma, mentioned that the Complainant was suffering from hypertension since last 20 years. The preauthorization form was not singed by the Complainant but it has the signature of unknown person. Depending upon the particulars of this form the Opposite Party No.2 had refused the cashless facility and then subsequently repudiated the claim.
6) The Complainant has stated that Dr. Sharma had also committed a mistake while recording a discharge summary wherein he had specifically alleged that the Complainant was suffering from hypertension for last 20 years. It was vehemently stated by the Complainant that at no point of time the Complainant had informed Dr. Sharma, that he was suffering from hypertension for last 20 years. In fact he had informed Dr. Sharma during his medical examination, that he was suffering form hypertension since last 20 to 25 months. Dr. Aniruddha Trivedi had also recorded the history of the Complainant and he has not mentioned this fact of hypertension of 20 years in his recorded history.
7) The Complainant has further stated that the Opposite Party No.1 has further made a statement in a letter dtd.16/10/06 that there was a break while renewing the policy in the year 1996. However, the Opposite Parties have not given any evidence to show that there was a break in renewing the policy in the year 1996. Thus, the Opposite Parties have repudiated the legitimate mediclaim of the Complainant on a illegal and vexatious grounds which are not true. Hence, the Complainant has prayed that the Opposite Parties be held liable jointly and severally for the deficiency in service as stated above and they may be directed to pay the legitimate claim of Rs.2,36,000/- with interest @ 15% p.a. form 01/03/06, the date on which the claim was made. The Complainant has also prayed that the Opposite Party be directed to pay a compensation of Rs.1 Lac for the harassment caused to the Complainant and the cost of this complaint.
8) The Complainant has attached the xerox copies of the following documents in support of his complaint –
Schedule of the 1st policy (1985-86), Claim form, Policy Schedule for the year 2004, 2003, 2002, 2001, 2000, 1999, 1998, 1997. 1996. 1995, 1994, 1993, 1992, 1991, 1990, 1989, 1988, 1987, 1986, Policy Schedule 2005-2006, Discharge Card of Bombay Hospital, Hospital Papers and receipts of medicines, Letter dtd.22/05/06, 16/10/06.
9) The complaint was admitted and notices were served on the Opposite Parties. Opposite Party No.2 did not appear before this Forum inspite of service of notice of the complaint on it. Hence, ex-parte order was passed against Opposite Party No.2.
10) Opposite Party No.1 appeared before this Forum through its Ld.Advocate and filed its written statement, wherein it admitted that the Complainant initially took a mediclaim policy on 02/08/85. Further the Opposite Party No.1 has emphasized on exclusion clause 4.1 which states that all diseases/injuries which are pre-existing when the cover incepts for the first time. For the purpose of applying this condition, the date of inception of initial mediclaim policy taken from any of the Indian Insurance Companies shall be taken provided the renewal have been continuous and without break.
11) It is further submitted by the Opposite Party No.1 that, the said policy was renewed in the month of July time to time until 1996 on yearly basis. However, the Complainant did not renew the said policy in time in the year 1996 and 1998 as a result of which, there was a break in the renewal of policy. Thus, the Opposite Party No.1 has pointed out that the said policy was regularly renewed and it was valid from July to July of every year till 1996. The last policy was valid from 28/07/95 to 27/07/96. In order to continue it this policy was to be renew before 27/07/96 but the next year policy was valid form 19/08/096 to 18/08/97. Similarly one year after i.e. in the year 1998-1999 the policy was valid form 08/09/98 to 07/09/99 instead of 19/08/98 to 18/08/99.
12) The Opposite Party has further stated that, the Complainant has approached Dr. Sharma in Jan., 2006 and in the course of his treatment Dr. Sharma reviewed the case history and reports of the Complainant. A case history in respect of a patient is drawn as narrated by the patient himself. The treating doctor under no circumstances makes any alterations/additions to the history narrated by the patient. Therefore, in the course of treatment and upon information given by the Complainant, Dr. Sharma, filled up pre-authorization form in respect of the cashless facility.
13) It is also submitted by the Opposite Party No.1 that upon conclusion of the treatment, Dr. Sharma, drew up the discharge card. The said discharge card also consists of details given by a patient. The said discharge card recorded the history, examination/findings as hyper tension for 20 years and diabetes for over 6-7 years. It further recorded that ‘Acute Coronary Syndrome” Angina and Hypertension is a common & proximate cause for coronary heart disease “Angina”. Therefore, the claim was repudiated as the hypertension existed since last 20 years and which is a proximate cause of unstable Angina. Further, there was also a break in renewal of his policy, the case of the Complainant falls in exclusion clause 4.1.
14) It was further pointed out by the Opposite Party No.1 that as there was a break in renewal of the mediclaim policy in the year 1996, and 1998, the Complainant was effectively holding the said policy from 08/09/98 only. The Opposite Party has specifically denied the averment of the Complainant that the Complainant has renewed the policy since 02/08/85 in continuity. Finally the Opposite Party No.1 has stated that the Complainant is not entitled to any relief as claimed in his complaint. The Opposite Party No.1 has attached the terms and conditions of the insurance policy, Preauthorization form and an illegible document issued by Bombay Hospital and Medical Research Centre. Thereafter, the Complainant has filed affidavit in rejoinder and a written argument wherein he reiterated the facts and points mentioned in his complaint.
15) We heard the Ld.Advocate for the Complainant and perused the papers submitted by both the parties and our findings are as follows –
The Complainant has obtained a Mediclaim Policy at first time in 1985, which was valid from 02/08/1985 to 01/08/86. We have carefully gone through all the policy documents from 1985 to 2006, and it appears that there is a gap in renewing the policy in the year 1996. The policy for the year 1995-1996 is valid till 27/07/1996. The next policy started on 19/08/1996. Therefore, it was not in continuation of the previous mediclaim policy. Similarly the policy for the year 1997-1998 is valid from 19/08/1997 – 18/08/1998. But the next policy started on 08/09/1998 instead of before 18/08/1998. Therefore, this policy is also not in continuation of the previous policy. However, since 08/09/1998, the medical policies are in continuation and without break.
16) Having valid mediclaim policy in the year 2006, the Complainant was hospitalized in Bombay Hospital for Angiography and heart surgery for unstable Angina (Acute Coronary Syndrome Coronary Artery disease in Jan. & Feb., 2006. (During the validity of the mediclaim policy). After getting discharge from the said hospital the Complainant filed his mediclaim of Rs.2,36,000 vide his application dtd.01/03/06. The Opposite Party No.2 rejected the said claim vide its letter dtd.22/03/06 on the ground that the Complainant has history of hypertension since last 20 years and it is a proximate cause of unstable Angina. Therefore, hypertension is pre-existing before inception of the policy and hence, the claim is not payable under clause 4.1 of the insurance policy.
17) The Opposite Party No.1 has already reproduced the clause 4.1 according to which the Opposite Party No.1 is not liable to pay the expenses incurred in respect of the disease which are pre-existing when the cover incepts for the 1st time provided that the renewals have been continuous and without any break. In this case it is the contention of the Opposite Party that the Complainant was suffering from hypertension since last 20 year4s before the surgery and hence, the hypertension was a pre-existing condition before the inception of the policy.
18) The Opposite Party has mentioned about the discontinuation of policy in the year 1996 and 1998. In the written statement they pointed out that there was a break of some days in renewal of the policy in the year 1996 and 1998 therefore, hypertension was a pre-existing disease. Though technically there is a break in renewal of these polices as stated by the Opposite Party No.1, and as per the record prepared by the treating doctor, Shri. Satyawan Sharma, the hypertension existed some 20 years before the surgery of the Complainant for unstable Angina. In our candid view the patient was suffering from unstable Angina a heart ailment (Acute Coronary Syndrome) in the month of Jan., & Feb., 2006. Definitely Hypertension is not an Acute Coronary Syndrome or a Unstable Angina. The surgery performed on the Complainant was not for hypertension. The Unstable Angina of the heart (Acute Coronary Syndrome) was not in existent before 08/09/1998. In our candid view, Hypertension and Unstable Angina are altogether two different diseases. The Complainant was hospitalized for Unstable Angina and not for hypertension. The Unstable Angina was not a pre-existing disease within the meaning of clause 4.1 of the terms and conditions of the mediclaim policy and hence, the repudiation of the insurance claim of the Complainant by Opposite Parties on the above said ground, certainly amounts to deficiency in service and the Complainant is entitled for his insurance claim. However, it is seen from the schedule of the policy document of year 2005-2006 (concerned policy) that the sum insured is only Rs.1,50,000/- for the Complainant and the accumulated bonus amount is Rs.50,000/-. The claim of the Complainant is of Rs.2,36,000/-. The Complainant is also entitled for the compensation for mental agony but prayer of the Complainant for Rs.1,00,000/- as a compensation is exorbitant. The Complainant is also entitled for the cost of this complaint. Therefore, in view of the above observations, we pass the following order–
O R D E R
i. Complaint No.464/2006 is partly allowed.
ii. Opposite Parties are directedto pay jointly and/or severally an amount of Rs.2,00,000/- (Rs. Two Lacs Only) to
the Complainant towards his mediclaim submitted by him on 01/03/2006 with interest @ 9% p.a. from
22/03/2006 till its payment.
iii.Opposite Parties are directed to pay jointly and/or severally an amount of Rs.10,000/- (Rs. Ten Thousand Only)
to the Complainant for mental agony caused to him because of deficiency in service on the part of Opposite
Parties.
iv.Opposite Parties are also directed to pay jointly and/or severally Rs.5,000/- (Rs. Five Thousand Only) to the
Complainant towards the cost of this compliant.
v. Opposite Parties are directed to comply with the above said order jointly and/or severally within 30 days from
the receipt of this order.
vi.Certified copies of this order be furnished to the parties free of cost.
