Order-15.
Date-20/03/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the complainant, in short, is that the complainant obtained a policy from the OP being policy no.CE00047747000106 covering a period from 23-11-2015 to 22-11-2016 under daily hospital benefit of Rs.1,500/- having premium of Rs.2,012/- through its agent, Standard Chartered Bank(OP3). During subsistence of policy the complainant took an admission in Ramkrishna Mission Seba Pratisthan on 21-02-2016 and was discharged on 21-03-2016 for the treatment of severe Bronchial Asthama which has been clearly stated in the discharge certificate. The complainant, thereafter, alleged the claim to the insurance company for disbursement of the claim on 31-03-2016 along with all supporting documents which the insurance company received and the OP Company vide letter dated 08-06-2016 informed the complainant that the OP shall not be liable to make any payment as the medical record shows it is the case of pre-existing disease. The complainant has alleged that he has not suppressed any material fact and the OP Company has not taken necessary formalities before issuing the policy. It is also stated that the insurance company has panel of doctors and insurance company ought not to have issued a policy in favour of the complainant until and unless satisfied by its doctors. The plea of pre-existing disease is not tenable. The complainant has alleged that the OP has repudiated the claim illegally and arbitrarily. The complainant also served legal notice dated 14-06-2016 to release the claim but to no good. Hence, this case.
OPs 1 and 2 have contested the case in filing written version contending, inter alia, that the complaint is not maintainable and the OPs have not committed any deficiency in service or unfair trade. It is stated that the complainant had taken the policy Hospital Cash Plan through Standar Chartered Bank customer for himself for the period of insurance from 23-11-2015 to 22-11-2016 subject to the terms and conditions therein. The subject policy is a fixed benefit policy wherein pre-existing disease are permanently excluded. It is stated that the complainant had lodged a claim in respect of hospitalization at Ramkrishna Mission Seva Pratisthan for the period of admission from 21-02-2016 to 21-03-2016 for the treatment of acute severe Bronchial Asthama. The answering OPs on receiving the claim instructed the investigator to obtain the hospitalization documents and records and on scrutiny of the records it was clearly revealed that the complainant was Asthamatic from childhood. It is stated that the OP is not liable to pay hospitalization expenses for pre-existing disease. It is stated that the claim falls within the exclusion clause and, as such, the claim is denied. It is stated that there is no deficiency or unfair trade practice on the part of the OPs. OPs prayed for dismissal of the case.
Point for Decision
- Whether the OPs have been deficient in rendering services to the complainant?
- Whether the OPs have repudiated the claim rightly or arbitrarily?
Decision with Reasons
We have perused the documents on record i.e. Xerox copy of insurance policy along with policy papers, Xerox copy of discharge certificate of Ramkrishna Mission Seva Pratisthan, Xerox copy of outdoor registration of the said hospital, Xerox copy of certificate dated 06-06-2016 issued by Registrar/RMO of Department of Medicine, Ramkrishna Mission Seva Pratisthan, Xerox copy of authorized letter dated 22-03-2016, Xerox copy of PAN Card, Xerox copy of letter dated 04-11-2015 of OP, Xerox copy of repudiation letter of the OP dated 08-06-2016, Xerox copy of legal notice dated 14-07-2016 and other documents on record.
It appears that the complainant took an insurance policy being policy no.CE0004774700016 from the OP Company with coverage from 23-11-2015 to 22-11-2016. It also appears from the written version of the OPs that the said policy was issued 7 years back with continuous coverage with the OPs. It also appears that according to the said terms and condition of the policy of insurance the complainant would be entitled to Rs.1,500/- per day in case of indoor admission in a hospital. He was admitted in Ramkrishna Mission Seva Pratisthan and found to be suffering from acute severe bronchial asthma. He was in Ramkrishna Mission Seva Pratisthan from 21-02-2016 to 20-03-2016. It was found that the complainant was asthmatic since childhood days, as per doctor’s prescription. OPs as we find repudiated the claim as the complainant got admitted for acute severe bronchial asthma as mentioned in the discharge summary. It is stated that the medical reports reveals that the complainant had symptoms prior to policy inception and hence this preexisting medical condition is excluded from the scope of the policy.
The question is whether the bronchial asthma can be termed as a disease excluded under the exclusion clause in the policy. In the exclusion clause we find that certain diseases are furnished namely any heart, kidney, circulatory disorder in respect of insured person. We find that the complainant took the policy 7 years back and the policy was issued for the 7th year of continuous coverage for the period 23-01-2015 to 22-01-2016. We find that acute severe bronchial asthma is not included in the exclusion clause in the policy. So, we do not think that the insurance company has been justified in repudiating the claim of the complainant. Firstly, preexisting disease is not defined in clear terms in the policy literature. Moreover, the names of certain diseases have furnished in the exclusion clause of the plan. “Acute severe bronchial asthma” does not appear to be any such disease in the list. So, we are constrained to hold that the OPs have not been justified in repudiating the claim just on the ground that it is a pre-existing disease.
Moreover, we find that insurance company is maintaining a panel of doctors for itself and they are supposed to checking a patient before issuance of the insurance policy.
It also appears that the complainant took the policy 7 years back and the policy is renewed year to year thereafter. It is also the responsibility of the insurance company to check a patient before issuance of insurance policy to ascertain or find out whether the incumbent is fit for mediclaim insurance policy or not or for its own satisfaction. Simple repudiation that the disease is pre-existing is not sufficient. There is no document filed from the side of the insurance company before us to establish that the present complication of the patient took place as a complication of pre-existing disease or for HTN, D1DM2, Prostatomology. There is also no document to show that bronchial asthma was the resultant effect of HTN, DM2 or prostatomology. We think that repudiation of the claim of the complainant is not justified and in repudiating the claim the insurance company has exhibited a gesture of deficiency in service.
In result, the case merits success.
Hence,
Ordered
That the instant case be and the same is allowed on contest against O.Ps.-1 and 2 and ex-parte against O.P.-3.
OPs 1 and 2 are jointly and severally directed to make payment of the daily benefit at the rate ofRs.1,500/- per day during the period of admission of the complainant from 21-02-2016 to 21-03-2016 at hospital within one month from the date of this order.
OPs 1 and 2 are also jointly and severally directed to pay an amount of Rs.10,000/- for causing harassment, mental pain and agony to the complainant apart from litigation cost of Rs.5,000/- within the stipulated period.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P. Act and in that case OPs 1 and 2 shall be liable to pay penal damage at the rate ofRs.5,000/- per month to be paid to this Forum till full and final satisfaction of the decree.
We make no order as against OP3.
