Sri S.K.Sahoo,President.
This is a complaint filed by one Bhibhuti Bhusan Samal on 19.4.2021 U/s. 35 of C.P.Act2019 for some reliefs.
2. The case of the complainant is that he opted and obtained one Family Health Insurance Policy from opp.party No.1 & 2 through its branch office situated at Bhubaneswar . The policy issued to the complainant was bearing No.10839056 of Oct.2016. It was valid from 18th Oct. 2016 to 27th Nov.2019. opp.party No.3 is the intermediary in between the complainant and opp.party No.1&2 . The complainant has claimed no relief against opp.party No.3 but he is a necessary party for just decision of this case. Initially the complainant has paid an amount of Rs.12029.00 to opp.party No.1 towards premium of the policy and subsequently paid an amount of Rs.14606.00 for renewal of the policy which covered from 28th Nov.2018 to 27th Nov.2019. The complainant, his wife Subhashree Samal, daughter Sania Priyadarshani Samal and son Rajdeep Samal are the beneficiaries of the aforesaid policy. After receiving the premium opp.party No.1 issued policy certificate in favour of the complainant along with premium acknowledgment , key policy information, policy terms and conditions, claim process and health card. The sum assured was Rs.4,00,000.00. In the month of April 2019 the wife of the complainant suffered Severe abdomen pain. An ovarian cyst was detected which needs immediate removal through laparoscopic adhesiolysis. Subhashree Samal the wife of the complainant happens to be nominee/secondary insured member under the policy. Mrs. Subhashree Samal was admitted as an inpatient in the hospital of OP No.3 on 01.05.2019 and continued as such till 06.05.2019. She was subjected to laparoscopic ovarian cystectomy . After her discharge, the complainant made the claim towards the expenditure for her treatment before the opp.party No.1 through opp.party No.3, who submitted the claim Rs.95,237.80. All the required documents for settlement of the claim were also submitted along with the claim. After receiving the claim by opp.party No.1 on the same day an intimation was issued to the complainant through opp.party No.3 that the claim of the complainant has been rejected due to non disclosure of material facts/pre existing ailments at the time of submission of the proposal although the patient is aware of known case of diabetes melutus prior to the inception of the policy for which the initial approval stands null and void. On query by the complainant he came to know that his claim has been rejected due to wrong mention of treating doctor regarding the suffering period of diabetes as 3 to 4 years instead of 3 to 4 months. Such opinion of the treating doctor in the patient’s PAC of opp.party No.3 is not based on pathological examination Subsequently the treating doctor of opp.party No.3 has clarified and intimated the same to opp.party No.1 . Inspite of receipt of such opinion from opp.party No.3. the opp.party No.1 did not review the decision of rejection of the claim made by the complainant. The complainant also made repeated request to the opp.party No.1 to reconsider the rejection of the claim in view of the clarification given by the treating doctor of the opp.party No.3. Hence this case.
3. Notice was issued to all the opp.parties through Regd. post with A.D on 25.08.2022 by this Commission, directing them to appear on 28.10.2022 and file show cause. Opp.party No.3 appeared and filed the show cause, where as opp.party No.1 & 2 neither appeared before this Commission nor filed show cause or contested this case. The notices issued to opp.party No.1 & 2 are not received back nor the A.Ds . The notices issued to opp.party No.1 & 2 were deemed to be duly served on them in view of Section-27 of General Clauses Act, which has been reflected vide order dtd.17.11.2022.
The case of the opp.party No.3 is that the patient namely Subhashree Samal was treated by opp.party No.3 who was admitted as an in patient on 01.05,2019 and discharged on 06.05.2019 after surgery on 02.05.2019 .The patient was diagnosed for blood glucose (random) test on 01.05.2022 as a pre-surgery diagnosed to which the sugar level of the patient was under normal biological reference limits .The blood sugar test of the patient was made out pre and post surgery does not suggest the patient to be diabetes, even though the patient w as diabetes ,the diagnosed reports suggest that her blood sugar level during that time was under controlled limits and under normal biological reference limits. No inference can be medically drawn from the blood glucose test reports regarding the time since when the patient has been suffering from diabetes .There is no procedure or test to be done to ascertain the patient’s history of diabetes. The diagnosed done by the hospital is insufficient to suggest and derived any kind of opinion regarding the period since when the patient has been suffering from diabetes. The PAC sheet is not the concrete evidence of proof to establish the date since when the patient is suffering from diabetes. The certificate issued by the doctor is purely based upon the statement of the patient/ NOK of patient and is made to bring a change/rectification to the PAC sheets .
4. The complainant has not produced any evidence during hearing of the case. The complaint petition filed by the complainant is supported with affidavit. In his complaint petition the complainant has mentioned that he has obtained Family Health Insurance Policy bearing No. 10839056 from opp.party No.1 & 2, which was initially valid from 18.10.2016 to mid night of 17.10.2017 and renewed for the period 28.11.2011 to mid night of 27.11.2019 on payment of premium of Rs.14,606.00 . It is further averred in the complaint petition that in the month of April, 2019 the wife of the complainant sustained pain on her abdomen and detected developed ovarian cysts, which needs immediate removal and accordingly she was admitted to the hospital of opp.party No.3 on 01.05.2019 and discharged on 06.05.2019 after surgery. According to the complainant an amount of Rs.95,238.83 was spent for the treatment of his wife Subhashree Samal and when opp.party No.3 submitted the claim of the complainant to opp.aprtyNo.1 & 2 it was rejected . The complainant has filed the photo copy of the policy certificates issued by the opp.party No.1 & 2 to the complainant on 21.11.2016 and 30.11.2018. On perusal of those certificates it is clear that the complainant, his wife Subhashree Samal, daughter Sania Priyadarshini Samal, son Rajdeep Samal were covered under the said policy for the period 28.11.2018 to 27.11.2019. Admittedly from the documents filed by the complainant it is clear that Subhashree Samal was subjected to surgery in the hospital of opp.party No.3 by spending an amount of Rs.95,238.83. From the initial pre-surgery test report of Subhashree Samal it appears that the doctor has opined that Subhashree Samal was a diabetes 3-4 years. However the photo copy of the another certificate issued by the treating doctor shows that he had wrongly mentioned 3-4 years instead of 3-4 months in the PAC issued to Subhashree Samal. So it is clear that the doctor who has treated Subhashree Samal admitted that she was suffering diabetes from 3-4 months prior to the test. However, no reason has been assigned by the doctor how he came to know that the age of the diabetes is 3-4 months. It is also admitted in the written statement filed by opp.party No.3 that there is no conclusive test to ascertain the age of the diabetes and the doctor has ascertained the diabetes of Subhashree Samal from the patient or NOK of patient. No material has been placed by opp.party No.3 from whom the treating doctor G.S.S Mohapatra or the doctor who has conducted the test on 01.05.2019 came to know about the age of the diabetes of Subhashree Samal .From the photo copy of the repudiation letter issued by opp.party No.1 & 2 in favour of the complainant/ her wife on 06.05,2019 it appears that the claim of the complainant has been rejected due to non-discloser of material facts/ pre-existing elements at the time of proposal and the patient is known case of diabetes mellitus prior to inception of the policy, for which the initial approval stands null and void.
Inspite of notice issued to opp.party No.1 & 2 in their correct address through Regd. post with A.D they did not turn-up to contest the case. On the other hand the claim of the complainant is supported by opp.party No.3. From the complaint petition and the documents filed by the complainant it is clear that Subhashree Samal, the wife of the complainant is covered under policy No. 10839056 from 28.11.2018 to mid night of 27.11.2019. It is also clear that she was under gone treatment in the hospital of opp.party No.3 by incurring an expenditure of Rs.95,237.80. There is no material before this Commission to conclude that there was non-disclosure of material facts/ pre-existing elements at the time of proposal given by the complainant .Hence refusal of the claim of the complainant by opp.party No.1 & 2 is not only illegal but also a clear case of unfair trade practice. There is a deficiency in service by opp.party No.1 & 2. The complainant and Subhashree Samal his wife were subjected to mental agony for such conduct of opp.party No.1 & 2. The complainant was also forced for litigation due to non-settlement of his legal claim . The opp.party No.1 & 2 both are jointly and severally liable for the claim of the complainant.
5. Hence ordered :-
: O R D E R :
The case be and same is allowed in part on contest against opp.party No.3 and exparte against opp.party No.1 & 2. The opp.partyNo.1 & 2 are directed to pay an amount of Rs.95,237.80 (Rupees Ninety Five thousand two hundred thirty seven and eighty paisa) only towards the treatment of Subhashree Samal, an amount of Rs.25,000.00(Rupees Twenty five thousand) only towards compensation for deficiency in service, an amount of Rs.25,000.00 (Rupees Twenty five thousand) only towards mental agony and unfair trade practice along with an amount of Rs.5,000.00(Rupees Five thousand) only towards cost of the litigation to the complainant with interest @ 7% per annum from 19.04.2021 till payment is made within a period of 30 days from the date of order, failing which the complainant is entitled to get penal interest @12% per annum.
