SMT. RAVI SUSHA: PRESIDENT
Complainant has filed this complaint U/s12 of Consumer Protection Act 1986 seeking to get an order directing opposite party to pay Rs.1,00,000/- with interest as the amount incurred for the medical expenses together with compensation to the complainant alleging deficiency in service on the part of opposite party.
The brief facts of the case as set out in the complaint are that the complainant had taken a medical insurance policy (SBI-Hospital Cash) on 18/05/2012 from the OP by paying an initial premium of Rs.4,236/- with No.46004853401 and sum assured Rs.2,00,000/-. All policy details are given to the complainant from the office of the OP. As per the explanation, the complainant had taken the policy. The policy was renewed in subsequent years and was in force when the claim was submitted by the complainant in the year 2016. The complainant, who is a bachelor, when was working Telengana state, had sudden acute stroke on 20/09/2015 and was admitted at Apex hospital, Karim Nagar, Telengana State. He came to the native place at Thalassery and was admitted at co-operative Hospital Thalassery on 27/09/2015 for the continuation of the treatment and was discharged on 07/10/2015. Then the complainant cannot move about without the help of another person, as the right side of the body is paralyzed and could not even sign with the right hand. Now the complainant is continuing the treatment in Ayurveda and also undergoing physiotherapy. The complainant claimed reimbursement from SBI Life for the medical expenses incurred amounting to Rs.77,671/- as per the terms of the policy and gave all the documents relating to medical expenses to the OP on 07/11/2015, at the office of SBI life Insurance company at Thalassery. The OP did not pay the amount, even after repeated reminders, in accordance with the terms of the policy. No reply is given by the OP showing the reason for denying the claim made by the complainant. Then the complainant filed a complaint f before the insurance ombudsman under Rule 13(1) b read along with Rule 14 of insurance ombudsman Rules, 2017. As per the letter received from the office of the insurance ombudsman dated 30/11/2018, informing the hearing of the case on 12/12/2018, the complainant sent the written statement, as the complainant could not go to Kochi. The case was dismissed as per the order dated 17/01/2019 stating that the matter is subjudice, as the case is pending before the Hon’ble district legal service authority. Hence filed this complaint.
OP resisted the claim of the complainant. It is contended by the OP that it is submitted that the complainant is disputing the terms and conditions of the policy which was issued in May 2012. The complainant is demanding benefits which are outside the scope of the terms and conditions of the policy. Hence the cause of action arisen, if any, was in May 2012 and the complaint is filed after a gap of 7 years. Hence the complaint is barred by limitation. Under the policy, the claimant needs to submit necessary documents to prove the genuineness of his claim for hospital cash benefits as per the terms and conditions of the policy. Any claim under the policy will be assessed as per the terms and conditions of the policy. In this instant case OP has called for requirements vide letters dated 15/12/2015, 31/12/2015, 16/02/2016, 03/03/2016 and 10/03/2016 and the complainant has not submitted the requirements even after sending these much reminders and hence the claim was treated as closed vide letter dated 31/03/2016. Another letter dated 01/05/2018 was also sent in this regard. The complainant has failed to produce any cogent evidence to prove deficiency in service on the part of the OP. Hence the complaint is liable to be dismissed in limine. The OP received intimation regarding the claim on 20/11/2015 and the same was acknowledged to the complainant vide letter date 20/11/2015. As per the claim intimation that complainant had informed regarding the hospitalization. As the complainant had not complied with the requirements, the OP had closed the claim vide letter dated 31/03/2016. These claim documents are necessary to examine whether the claim is admissible or not. Further, the OP reserves the right to call for further documents which are necessary to check the admissibility or otherwise of the claim. The OP reserves the right to decline the claim if the requirements are not satisfactory or if the claim is found not payable as per the terms and conditions of the policy. As per the terms and conditions the conditions of the policy document, if the claim is admitted then he will be eligible for the claim benefit of Rs.52,000/-. It is also submitted that in case the documents submitted to the OP fail to establish the genuineness or admissibility of the claim, the OP shall be within its rights to repudiate the claim as per the terms and conditions of the policy.
Both parties led their evidence. The complainant in proof of his case filed this affidavit evidence and got to the documents marked as Exts. A1 to A15, while that insurance company filed the affidavit evidence of its Divisional Manager and got the documents marked as Ext.B1 to B12.
After that the learned counsel of both parties filed their respective written argument notes.
The 1st plea raised by the OP is that the complaint is not maintainable as it is a time barred one filed after 7 years from the cause of action ie the policy was issued in May 2012. With regard to the said plea, it is seen that though the complainant was taken medical Insurance policy of OP on 18/05/2012, he has taken treatment on 20/09/2025 and claim application for reimbursement of medical expense was before insurance company was on 07/11/2015. Further after denial of claim, he has filed complaint before Insurance ombudsman on 2018; the said complaint was dismissed by Insurance ombudsman on 17/01/2019, with a direction to move a fresh application at any other forum/court. The instant complaint has been filed on 22/06/2019 within a period of 2 years as per sec.24 of Consumer Protection Act 1986. So there is no delay or limitation in filing this complaint and hence this complaint is maintainable. The 1st plea thus decided in favour of the complainant.
The 2nd point to be decided is whether there is deficiency in service on the part of OP in denying the Insurance claim of complainant?
It is an admitted fact that complainant had taken a medical insurance claim with OP on 18/05/2012 having policy No.46004853401 for an assured sum Rs.2,00,000/- and paid the initial premium of Rs.4,236/- which was renewed in subsequent years and was in force in the year 2016. It is also an admitted fact that complainant had happened sudden acute stroke on 20/09/2015 and was admitted at Apex hospital, Karim Nagar, Telengana state;. Further there is no dispute that the complainant was subsequently admitted at co-operative Hospital Talassery on 27/09/2015. There is not dispute that there was active policy to the insured during the treatment period and was discharged on 07/10/2015. Further admitted fact that on 07/11/2015, the insured had submitted claim application to OP SBI life for reimbursement of medical expenses incurred to him for an amount of Rs.77,671/- Further undisputed fact that after receiving claim form, OP had called for the documents to complainant on 15/12/2015 related about the duration of diabetes and hypertension, since when, certified by the treating doctor, supported by the 1st consultation paper (Ext.B4). Further in reply to the said letter dated 11/01/2016, stating that diabetes and acute stroke was observed on 20/09/2015 and immediately treatment was carried out under Dr.Bharath Kumar of Apex Hospital, Telengana.(Ext.A5). Further OP has issued subsequent letters on different dates. Ext.B5 to B10 stating that the reply (Ext.A5) received from the complainant is not sufficient and finally on 31/03/2016 OP had sent a claim closure letter to the Insured complainant stated that the claim application of complainant was closed as “ No claim” with a reason of non-submission of necessary documents.
OP submits that as the requisite documents for checking the admissibility of the claim were not received despite several remainders the claim was closed as ‘No claim’ and the closure letter was sent to the complainant. OP further submitted that as per the claim intimation complainant will be eligible for Rs.52,000/- only as per the terms and conditions of the policy on submission of required documents: OP submitted in Ext.B2 the policy document containing the terms and conditions and stated that hospital benefits is eligible only to treatment availed in allopathic treatment by a qualified allopathic medical practitioner holding a valid license registered with medical counsel of India. On perusal of Ext.B2 policy documents, it its clearly mentioned in clause 2(19) and 2 (30) that the policy covers only medical expenses incurred for allopathic treatment only.
Here with regard to the point about whether insured had pre-existing disease of diabetes and hypertension, complainant replied that since he had not undergone any treatment for the diabetes and hypertension prior the hospitalization in dispute, he could not submit such a treatment expense as instructed by OP, before OP. As per Ext. A6 dated 15/09/2016 it is revealed that along with claim for, complainant had submitted all required documents (a) Treating doctor’s certificates from two hospitals, ie apex hospital Telangana and Tellichery co-operative hospital. Thalassery, (B) discharged card, (c) documents related to hospitalization (d) details of his bank account etc. During cross-examination the complainant answered to the question of learned counsel of OP, about the submission of photocopies of medical records and bill, that he could not remember about originals. Since Ext.A6 shows that complainant had sent the above relevant documents regarding hospitalization, he might have sent the originals of the medical records to the Insurance company along with claim form. Though there is no dispute regarding hospitalization during the claim period, the documents submitted by complainant Ext.A3, can be accepted. On perusal of Ext.A3, certificate of hospital treatment issued by Dr.Bharath kumar, medical Superintendent, apex hospital Telingana, date 27/10/2015, it is revealed that (1) nature of complaint ‘sudden set of weakness in Right upper limb and low limb. (2) What was the exact history reported by the patient at the time of admission HTN/DM. Though Ext.A3 found that there was history of hypertension and diabetes, the duration of history is not mentioned. There is no dispute that the complainant had taken the policy in the year 2012. The disputed hospitalization happened on 20/09/2015. The only evidence on record about the disease of diabetes and hypertension of the insured in Ext.A3. But in the past history, from which date on wards, complainant had been suffering from diabetes and hypertension and was undergone treatment is not revealed. If there had been specific period, showing the treatment before taking the policy, the matter would have different. The mere statement that the insured is having history of diabetes and hypertension is not sufficient proof justifying repudiation of the claim. The insurance company should have hold an enquiry also to find out whether the complainant was really suffering from diabetes and hypertension prior to taking of policy and was taking treatment for that. Where no treatment record prior to proposal is produced, we feel that the repudiation on the basis of assumption is not justified. The insurance company has failed to placed on record any documentary evidence to indicate that the insured had taken the treatment for diabetes and hypertension before the policy. Hence the contention of the insurance company that the insured had suppressed his pre-existing disease in the proposal form is not acceptable in absence of any evidence in support. So we are of the view that the repudiation made by OP Insurance Company cannot be justifiable.
Hence repudiation of claim application of the insured, who was suffering from acute stroke, without any cogent evidence, after receiving premium amount, is a gross deficiency in service on the part OP Insurance Company. Complainant is eligible to get policy benefit is hospitalization expenses from the Insurance company. OP ought to have sent the eligible claim amount thorough the bank account furnished by complainant along with claim form.
Here as per the policy condition no clause 2 (19) and (30), insured is eligible to get treatment expense only for allopathic treatment availed from allopathic medical practitioner. So considering the said condition, complainant is entitled to get total room charges and ICU charges & medical expenses incurred to the complainant at two hospitals Apex Hospital, Telengana and co-operative hospital Thalassery Rs.7,7671/- with interest.
In the result complaint is allowed in part. Opposite party is directed to pay Rs.77,671/- to the complainant with interest @ 7% per annum from the date of repudiation of claim application of the complainant 31/03/2016 till the date of realization. Opposite party is also directed to pay Rs.10,000/- towards compensation Opposite party shall comply the order within one month from the date of receipt of this order, failing which the awarded amount carries interest 12% from 31/03/2016 till realization. Complainant is at liberty to execute the order as per provision of Consumer Protection Act 2019.
Exts.
A1- Letter issued from Insurance ombudsman
A2- Insurance ombudsman award copy
A3- Certificate of hospital treatment (subject to proof)
A4- Copy of letter to OP showing the document given by the complainant
A5- Copy letter regarding hospitalisation
A6- Claim letter by complainant to OP.
A7- Complainant given by the complainant to OP
A8- Letter given by the complainant regarding the non-settlement of the claim
A9- Discharge bill Thalassery co-operative hospital
A10- Medical bills (8 in numbers)
A11- Statement given by the Apex hospital Telungana
A12- Discharge summary Sanjeevani Ayurvedic hospital Thalasseri
A13- Consolidated bills of Sanjeevani Ayurvedic hospital Thalasseri
A14- Medical board certificate
A15- Original policy
Pw1-Complainant
B1-Copy of Proposal form
B2-Policy document copy
B3-Claim registration account
B4-Letter send by OP to complainant dated 15/12/2015
B5- Reminder letter
B6- Final reminder letter dated 31/12/2015
B7- Requirement letter
B8- Reminder letter dated 03/03/2016
B9- Final Reminder letter dated 10/03/2016
B10- Final Reminder letter dated 10/03/2016
B11- Claim closure letter dated 31/03/2016
B12- Final Reminder letter dated 01/05/2018
Dw1-Shylendran V C- Witness of OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
