Order-15.
Date-08/09/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short is that Complainant obtained an Insurance coverage under the policy name and style “ CARE “ being Policy No.10211045 from OP-1 on 02.03.2015. The Policy was issued in the name of the Complainant as insured giving coverage to the Complainant and his wife being beneficiary in the event of any Hospitalization Benefit during the period on and from 02.03.2015 to midnight of 01.03.2016 for an overall capital sum insured of Rs.10,00,000/-. The Complainant regularly paid the premium of Rs.1,62,547/- in favour of OP-1 to 3. Subsequently, the said policy was renewed vide Policy No. 10221861 issued by OP-1 on 02.03.2016 and OP-1 accordingly, also issued a Policy certificate with validity up to 01.03.2019 upon receiving the premium of Rs.1,62,547/-. At the time of obtaining the policy the Complainant complied with all the formalities and also went through all the tests and check-up as per requirement of OP 1 to 3.
The wife of the Complainant namely, Ambalika Kundu suffered from some gynecological problem and consulted with one Doctor namely, Dr. Goutam Khastgir at Kolkata on 11.01.2016 and the said doctor prescribed some medicines and advised her to get admitted before OP-4 under Dr. Goutam Khastgir on 24.06.2016 for treatment and operation and she was discharged on 29.06.2016. During the aforesaid period of treatment the wife of the Complainant had undergone various medical tests and investigations and during her hospitalization her uterus was removed and umbilical hernia was repaired. During treatment the Complainant incurred an expenditure of Rs.1,62,547/-. The Complainant submitted a claim before the OP-2 for availing the hospitalization expenses from OP 1 to 3 amounting to Rs.1,62,547/- along with all original documents as asked for by OP-1 to 3. The OP-1 to 3 did not show any intention to release the amount. The Complainant waited for two months, but OP-1 to 3 did not respond. Surprisingly, after expiry of few months, OP-1 to 3 on 04.10.2016 issued a purported letter intimating the Complainant that the claim has been repudiated on the ground of non disclosure of material fact/pre-existing ailments at the time of proposal and also for hypertension diabetes since 02 years 6 moths. The Complainant got astonished and made correspondence with OP-1 to 3 replying and denying the allegations as raised by OP-1 to 3, but to no good. It is also alleged that there is no whisper as to the alleged condition in the terms and conditions of the policy for which OP-1 raised objection vide letter dated 04.10.2016.It is also alleged that OPs never supplied any policy papers to the Complainant as and excepting the policy certificate. The Complainant has alleged deficiency of service against OPs. It is stated that the claim of the Complainant has been repudiated illegally and without any basis. The Complainant has prayed a direction on the OPs to release the claimed amount along with other reliefs in terms of prayer in the petition of complainant.
OPs-1 to 3 have contested the case in filing w.v. contending inter alia that the case is not maintainable in law and in fact and is liable to be dismissed in limine.
It is stated that at the time of taking the policy the Complainant submitted proposal form duly filled-in and signed by him and as per proposal form the proposed insured person has to provide all the information required therein correctly and or truly. The Complainant approached the Answering OP for reimbursement of claim for hospitalization of the patient at Microlap Institute, Kolkata from 24.04.2016 till 29.06.2016 for the treatment of Uterine Fibroid. As per the Doctor notes dated 24.04.2016 prepared and maintained by the Hospital Authorities, the patient is stated to be having a history of diabetes mellitus and hypertension since 2 and half years. It is also stated that as per statement submitted by the Complainant to the investigator during the reimbursement of claim investigation the patient was of first diagnosed with hypertension, diabetes mellitus in between June and July, 2015. On the basis of above noted observations, the subject claim is rejected vide letter dated 04.10.2016 under Clause 6.1 and also for the terms and conditions for non disclosure of material facts as the patient was a known case of diabetes mellitus, hypertension for the past 2 and half years. It is alleged that Complainant had to disclose the patient’s pre-existing diseases. It is stated that the Insurance Policy is based on good faith and Complainant did not disclose the pre-existing ailments of the patient. These OPs have prayed for dismissal of the case.
Point for Decision
- Whether the OPs 1 to 3 are deficient in rendering service ?
- Whether the OP Insurance Company repudiated the Insurance Claim on valid ground?
- Whether Complainant is entitled to get relief as prayed for?
Decision with Reasons
We take all the points together for the sake of brevity and convenience of discussion.
Let us take a glance towards the documents on record i.e. photocopy of Policy Certificate, photocopy of premium receipt, photocopy of repudiation letter dated 4th October, 2016, photocopy of discharge summary, photocopies of prescriptions, photocopies of investigations, photocopies of Medical Bills, photocopies of emails on different dates as filed from the side of the Complainant.
We have also perused the documents filed from the side of the OPs i.e. photocopy of Welcome Kit, photocopy of Policy Certificate, photocopy of terms & conditions, photocopies of Proposal forms, photocopy of treatment sheet, photocopy of claim rejection letter, photocopy of check list from Religare Health Insurance Company Limited, photocopy of legal notice dated 29.04.2017 and other documents on record.
We find that Complainant had taken a Health Insurance Policy (CARE), bearing No.10211045 in the name of the Complainant issued on 02.03.2015 valid from 02.03.2015 to 01.03.2016, sum assured was Rs.10,00,000/-. We find subsequently the said policy was renewed vide Policy No. 10221861 issued by OP-1 on 02.03.2016 and accordingly, OP also issued a Policy Certificate with validity up to 01.03.2019 upon payment of the premium of Rs.1,62,547/-. The said policy was issued in the name of the Complainant and has insured by giving coverage to the Complainant and his wife being beneficiary in the event of any hospitalization benefit. The wife of the petitioner namely, Ambalika Kundu suffered from gynecological problem and was admitted at Microlap (OP-4) under Dr. Goutam Khastgir on 25.06.2016 for treatment and operation and she was discharged from OP-4 on 29.06.2016. The Complainant advanced claim before OP Insurance Company and such claim was repudiated by OP Insurance Company on the ground of non disclosure of material facts / pre-existing ailments at the time of the proposal and secondly, hypertension and diabetes since 2 years 6 months. It is worthy to point out at the very outset that the wife of the Complainant was admitted for large Uterine Fibroid as per the discharge summary. She underwent total Laparoscopic hysterectomy (TLH). So, we find that Complainant was not admitted in the Nursing Home either for hypertension or for any complicacy arising from diabetes. The present ailment for which the patient was admitted has no connection either with hypertension or diabetes. So, we think that repudiation of the claim on the ground of hypertension and diabetes is not sustainable. Moreover, it cannot be said that the Complainant suppressed any material fact connected with the present ailment or operation. Further we find that the tenure of the first policy was from 02.03.2-015 to 01.03.2016. We think that the Complainant suffered from some gynecological problem and went to Dr. Goutam Khastgir on 11.01.2016 and after intake of medicines and ultimately the petitioner’s wife got admitted on 25.06.2016. We find that OP also released the policy for the second time and issued policy No.10221861 on 02.03.2016 with validity up to 01.03.2019 upon payment of the premium of Rs.1,62,547/-. Moreover, in the policy certificate in the column, pre-existing disease, it is endorsed ‘None’. So, we do not think that the Complainant suppressed any material fact or about the pre-existing ailment at the time of proposal.
Be that as it may, the question is, can hypertension or DM-2 can be said to be a pre-existing disease for repudiation of any mediclaim? First of all it is pertinent to mention that OPs have not been able to produce any document to show that Complainant was suffering from hypertension or any disease prior to taking up of the policy or from DM-2. There is no proof that the Complainant’s wife was suffering any heart disease. Even if we take it for granted for argument sake that the Complainant was suffering from hypertension it cannot be said that every person suffering from hypertension is suffering from heart disease or would develop blockage in artery . There is also no such case that the insured was suffering from heart disease or any blockage in artery or she got admitted in hospital for any complicacy arising out of diabetes. Hypertension or diabetes is a common ailment and it can be controlled by medicine and it is not necessary that persons suffering from hypertension or diabetes would always get admitted in hospital.
We find that OPs subsequently also renewed the Policy. We find that OPs cannot cancel the subject policy or deny the claim when Insurance Company allowed the renewal of the Insurance Policy. It is astonishing that OPs have repudiated the claim, at the same time renewed the Policy. Moreover, in the instant case the wife of the Complainant was admitted in hospital for gynecological problems and not for hypertension or diabetes.
We think that renewal of the Policy operates as waiver and estoppel as against repudiation. We think that the repudiation is not valid and legal. The OP Insurance Company has administered a gesture of deficiency of service in repudiating the claim of the Complainant.
OPs be directed to release the claim accordingly.
Consequently, the case merits success.
Hence,
Ordered
That the instant case be and the same is allowed on contest against OP 1 to 3 and dismissed ex parte against OP 4 being the hospital.
OP 1 to 3 are jointly and severally directed to disburse the claim amount of Rs.1,62,547/- to the Complainant towards medical expenses apart from litigation cost of Rs.10,000/- within one month from the date of this order.
Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision in C.P. Act.
