By Smt. PREETHI SIVARAMAN.C, MEMBER

1.The complaint in short is as follows:-

         Complainant and his family have availed a Health Insurance policy of Max Bupa Health Insurance Company Limited for a period from 12/07/2019 to 11/07/2020 and  the same has been renewed up to 04/09/2022. Thereafter complainant had submitted a portability form to port the above insurance policy from Max Bupa Health Insurance Policy to Star Health Insurance Policy at the time of renewing the policy in the month of September 2022. At the time of  porting  from Max Bupa Health Insurance Policy to Star Health Insurance , the insurance agent  assured that  complainant and his family  will surely get  all the benefits and rights   in the  former policy  from  three years.

2.       In the month of October 2022  complainant’s wife experienced  cramp numbness, muscle spasm  and pain  on her hand  and she was seen  by the family doctor and took some medicines  and got temporary relief. The above pain again came in the month of December and the doctor suggested for seeing a neurologist. On 17/11/2022 complainant and his wife consulted with Dr. Rafeeq Ahammed at Korambayil Hospital, Manjeri and he suggested some test to complainant’s wife. When the test result got, it is seen that complainant’s wife had Carpel Tunnel Syndrome (CTS) and doctor suggested for a minor surgery. Then complainant called the insurance agent and the agent assured that complainant’s wife will get cashless treatment. 

3.     On 24/11/2022 the above doctor referred the case to the Ortho surgeon of that hospital and as per his advice she was admitted on that day. Then complainant got information from the insurance department of the hospital that they have received the pre-approval from the insurance company. But  at the time of discharge from the hospital, the insurance department of the hospital informed the complainant  that  the cashless claim was rejected  by the company  because  complainant’s wife had  the same disease which started six months ago. Hence they directed the complainant to pay the full amount spent for treatment in the hospital.

4.    Thereafter complainant submitted  the claim for reimbursement before the opposite party, but they rejected the claim of complainant stating the reason that  the patient  has been suffering  from CTS before 6 months  which is  prior to the  inception of  policy  in  Star Health Insurance.  It is a pre-existing disease or condition.

5.      Complainant again stated that the act of opposite party amounts to clear deficiency in service and unfair trade practice from their side and it caused mental agony, hardship and sufferings to complainant and his family. Hence this complaint. 6.      The prayer of the complainant is that, he is entitled to get Rs. 15,000/-  the amount he  already spent for his treatment, Rs. 50,000/- as compensation on account of deficiency in service  and unfair trade practice on the part of opposite parties and thereby caused mental agony, physical hardships and sufferings to the complainant and cost of the proceedings. 

7.            On admission of the complaint notice was issued to the opposite parties and notice served on them and they appeared before the Commission through their counsel and filed version.

8.          In their version, they denied all the allegations levelled by complainant against them except those which are admitted there under. They submitted that complainant and his wife Mrs Shavana and their children  were covered under a policy from MAX Bupa  Health Insurance Company for the  period from 12/07/2019 to 11/07/2020 and  the same has been renewed  up to  04/09/2022. Thereafter complainant had submitted a portability form to port the above policy from Max Bupa Health Insurance to Star Health Insurance and along with the form they had submitted a proposal form in which it was stated that persons insured under the policy were in good health and not suffering from any health issue. On the   basis of that, the opposite parties had issued  a policy  named as Family Health  Optima Insurance plan covering the  complainants’ wife  and their two children for the period  commencing from  05/09/2022 to  04/09/2023 for a sum insured of Rs. 3,00,000/- vide  policy No P/181312/01/2023/005378.

9.       At the time of availing the policy , complainant was  supplied with the terms and conditions of the policy  and   that were explained to the complainant  and the same was served to complainant  along with the  policy schedule.  It is also stated  in the policy schedule that “ the insurance  under this policy is subject to conditions , clauses, warrantees , exclusions etc.

10.      During the policy period ,  opposite parties received a request for  cashless hospitalisation from Korambayil Hospital, Manjeri stating that  wife of the complainant  was  admitted at the hospital  on  24/11/2022 and was  provisionally  diagnosed with  Carpel Tunnel Syndrome.  In the pre authorisation request for cash less treatment form, the treating doctor had noted in the duration of present ailment column as 6 months. From the available records it is clear that Shavana has been sufferings from CTS since 6 months which is prior to the inception of the policy and hence it is a pre-existing disease. As per the policy, pre-existing disease is  excluded under  exclusion No 3(1) A of the policy  which state that  company shall not be liable to make  any payments  under the policy  in respect of  any expenses  whatsoever incurred by the insured person in connection with or in respect of expenses  related to the  treatment of  a pre-existing disease and is direct complications  shall be excluded  until  the expiry of 48 months of  continuous coverage  after  the date of inception   of the  first policy with insurer. 

11.      Opposite parties  again stated that they rejected the authorisation for cashless treatment and was communicated to the hospital and complainant vide letter dated 24/11/2022. Thereafter complainant submitted claim form with discharge summary bills of Rs. 13,805/- and reports. As per the treatment records,  the insured patient had history of CTS since 6 months as on 24/11/2022,  hence it is  a pre-existing disease and they repudiated the claim and the same was informed to the complainant as per letter dated 17/01/2023. The claim of the complainant was repudiated as per the terms and conditions of the policy. There has been no unfair trade practice from the side of opposite parties. There is no deficiency of service from their side and complainant has not suffered any loss or damage due to the action of opposite parties. Hence complaint maybe dismissed.  

 12.            In order to substantiate the case of the complainant, he filed an affidavit in lieu of Chief examination and the documents he produced were marked as Ext. A1 to A7. Ext.A1 is the copy of repudiation of claim by opposite party dated 17/01/2023. Ext.A2 is the copy of rejection and withdrawal of approval given earlier sent by  opposite parties  to the Korambayil hospital , Manjeri dated 25/11/2022.  Ext.A3  is the copy of  outpatient  record of complainant’s wife dated 17/11/2022 (2 pages) . Ext. A4 is the copy of patient information dated 17/11/2022. Ext. A5 is the copy of discharge bill of complainant’s wife dated 24/11/2022. Ext.A6 series are the treatment bills of complainant’s wife. Ext. A7 is the copy of certificate given by Dr. Abussabah regarding the condition of complainant’s wife.  Thereafter opposite party also filed affidavit and documents which are marked as Ext. B1 to B5.  Ext. B1 is the copy of policy schedule and conditions. Ext.B2 is the copy of request for cashless hospitalization from Korambayil hospital, Manjeri.  Ext.B3 is the copy of   rejection of authorisation letter dated 24/11/2022. Ext. B4 is the copy of discharge summary from Korambayil hospital, Manjeri. Ext. B5 is the copy of repudiation letter dated 17/01/2023.

13.    Heard complainant and opposite parties. Perused affidavit and documents.  The following points arise for consideration:-

1. Whether there is any deficiency of service and unfair trade practice on the part of opposite parties.
2. If so, reliefs and cost.

14.Point No.1 and 2:-

         Case of the complainant is that, complainant and his family  have availed a Health Insurance policy of Max Bupa Health Insurance Company for a period from 12/07/2019 to  11/07/2020 and the same has been renewed  up to 04/09/2022 and  he had ported from  Max Bupa Health Insurance to Star Health Insurance  for  period commencing from 05/09/2022 to 04/09/2023 for a sum insured  of Rs 3,00,000/- vide policy No. P/181312/01/2023/005378.   The complainant stated that  his  wife experienced numbness, muscle spasm and pain on her hand  in the month of October 2022  and she was seen by the  family doctor  and took some medicines  and  the above pain again came and on 17/11/2022  they consulted with neurologist  and it is  seen that the  test result shows complainant’s wife had  Carpel Tunnel Syndrome and  on  24/11/2022 she was admitted in the hospital , but  opposite party rejected the cashless claim of complainant without any reason. 

15.       But opposite parties stated that, they repudiated the claim of complainant because the treating doctor had noted in the duration of present ailment column as 6 months. They again stated that complainant’s wife has been suffering from CTS since 6 months which is prior to the inception of the policy and hence it is a pre-existing disease. 

16.        As per Ext.A1 document, it is seen that opposite parties repudiated the claim of complainant stating the reason that the patient was suffering from CTS since 6 months as on 24/11/2022, which is prior to inception of medical insurance policy. Hence it is a pre-existing disease.  In Ext.A2 the rejection and withdrawal of approval given earlier the opposite parties stated the above facts and they also stated that the insured has failed to disclose this in his proposal form at the time of inception of the first policy. They again stated that as per the waiting period/exclusion No.01 of the policy, the claim for treatment of the disease is not admissible until the expiry of 12 months from 24/11/2022. Hence they are unable to approve the claim. Ext.A3, A5, A6 are the discharge bills and opposite parties also submitted that records of complainant’s wife before the Commission. In Ext.A7 the certificate given by  the Dr. Abussabah  to the Star Health  Insurance Company and he stated  that  complainant’s wife  admitted on 24/11/2022 with the complaint of numbness  on both hands  and the CTS is a  kind of disease which could have been developed in 2-6 months of time, but the patient consulted a neurologist first time on 17/11/2022  and as per the study report she was diagnosed to have CTS  and  she undergone  Carpel Tunnel  release under LA and discharged  from this hospital. 

17.   As per Ext.B1 document opposite parties also admitted that, complainant availed a Health Insurance policy from them and the ID card of complainant is also submitted by them. But the opposite parties justify the repudiation of the claim of complainant and contended that the complainant is not entitled to claim the amount under insurance coverage. In the version and affidavit the opposite parties categorically stated that the complainant had obtained insurance policy by suppressing material facts at the time of enrolment of the policy. It is contended by the opposite parties that they got legal right to repudiate the claim application submitted by the complainant. They again stated that as per the policy, pre-existing disease is  excluded under  exclusion No.3 (1) (A) of the policy  which states that  company shall not be liable to  make any payments  under policy  in respect of any expenses  incurred by the insured person   in connection with the expenses  related to the  treatment of pre -existing diseases . 

18.    In the evaluation of evidence available for settlement of disputes, the Commission finds that the reason stated for repudiation of claim is very feeble, baseless and against the interest of insured. From the documents,  we are on the opinion that complainant had  a health insurance policy of Max Bupa  from 12/07/2019 onwards and at the time of renewal  on 04/09/2022  he ported  the above insurance policy from Max Bupa to Star Health. It is a continuation and  he just  ported from  one insurance policy to  another without any interruption. There is no case for opposite parties that there is a lapse of some months or there was interruption in the policy period of complainant when he was jumped from one policy to another. From the documents it is clear that there is no lag or lapse of months during the porting of one insurance policy to another.  There is no case like that also.  That means complainant and his family have insurance policy from 2019  till 04/09/2023. Opposite parties admitted that  their Family Health Optima Insurance Plan covering the complainant’s wife and their two children  for the period commencing from 05/09/2022 to 04/09/2023 and the sum insured is Rs.3,00,000/-19.        Nobody will port from one insurance policy to another if the benefits are lost from the earlier policy.  There is no use for the insured by porting from one insurance policy to another. In this complaint, complainant also stated that the agent of opposite parties insisted him to port from Max Bupa Insurance Policy to Star Health Insurance Policy. There is no special benefit for complainant and his family for porting from one insurance to another. Opposite parties also not stated that complainant had got some benefits due to the porting of policy from Max Bupa to their insurance policy.

20.     While analysing evidence adduced by both parties it can be seen that the opposite parties admitted the insurance coverage and the claim was made during the period of coverage. From the documents and from the admission of opposite parties it is clear that from 2019 onwards complainant and his family were under the insurance coverage. In this matter opposite parties stated that at the time of availing the policy, complainant was supplied with terms and conditions of the policy and it is clearly stated in the policy schedule that “the insurance under the policy is subject to conditions, clauses, exclusions etc’’. Opposite parties stated that as per the treatment records the insured patient had history of CTS since 6 months as on 24/11/2022 and it is a pre-existing disease. From the complaint and documents of complainant, it is seen that complainant’s wife had some numbness and pain  on her hand  in the month of October 2022 and  she consulted with her family doctor  and took some medicines and  got temporary relief. They again stated that   the pain  and numbness again came  and on 17/11/2022  they consulted with Dr. Refeeq  and on 24/11/2022  the above doctor  referred the case to Ortho surgeon and as per his advice  complainant’s wife  has  admitted on that day    and opposite party  rejected  the cashless  claim of complainant  because  it is a pre existing disease. But  there is no document produced by  opposite parties to prove that  the above mentioned CTS  was  pre existing  and  complainant’s wife had  taken treatment before 6 months . As per Ext.B2 Dr. Abussabah stated that the nature of illness is CTS and the duration of the present ailment is 6 months. But there is no document to prove that   complainant had taken medicines and treatment for CTS.  Doctor just stated that the pain and numbness was there without  presenting  documents to substantiate the same.

21.     Moreover  in Ext.B3 and B5 opposite parties stated that  the patient has been suffering from CTS since 6 months which is prior to the inception of policy in Star Health.  But as per complainant’s case  he  availed this policy from Max Bupa Health Insurance  from 2019 onwards. There is no document to prove that  there is a  lapse of time  from the side of complainant in renewing the policy or some other matter. Opposite parties also admitted that the policy renewal date was on 04/09/2022 and complainant had taken the policy of Star Health Insurance from 05/09/2022 itself. That means without interruption complainant had renewed and ported the policy. So  the second contention of opposite parties,  that means the CTS  of  complainant’s wife since  6 months  which is prior to inception of policy is  not at all taken into consideration. As per complainant’s case, his wife had experienced numbness and pain on October 2022 which is in the continuation of the policy period. Moreover there is no document to prove that she had treated for the pain and numbness experienced before 1 month. There is no prescription or nothing to prove the same by opposite parties.   Hence there is no pre-existing disease   to complainant.

22.    As  per Ext.A7 document,  Dr. Abussabah  the same doctor mentioned above  stated that CTS is a kind of disease which could have been  developed in  2-6  months of time  and  he again stated that the patient consulted a neurologist first time on 17/11/2022 and  she was diagnosed to have CTS  and she undergone  Carpel Tunnel release under LA. From that document it is very clear that there is no pre-existing disease to complainant.  So there is no need to repudiate the claim of complainant.  The disease came during the pendency of insurance policy which is taken in 2019 and thereafter complainant ported to opposite party’s insurance policy.  As per documents from both sides it is clear that she had approached her family doctor on October 2022. 

23.      Opposite parties failed to adduce any documentary evidence to show that complainant had undergone treatment prior to the inception of policy. They did not   produce any documents to show the pre-existing disease of the wife of complainant.

Any kind of opinion or remark without valid proof cannot be accepted by the Commission especially in a situation where the right of the party is under challenge. Hence the Commission cannot find any kind of violation of the terms and conditions of the policy from the side of complainant. Moreover complainant and his family are under the protection of insurance policy from 2019 onwards till now.  The Commission finds that opposite parties had committed deficiency in service   towards the complainant’s wife by repudiating the claim without any valid reason. In their version and affidavit opposite parties stated that the patient had discharged on 24/11/2022 and complainant submitted claim form with discharge summary, bills of Rs 13,805/- and reports. From the above statement it is clear that complainant submitted the treatment records and bills in time without any delay. The Commission also finds that the complainant and his family had undergone mental agony and hardship due to the act of opposite parties. The denial of insurance to the right claimant amounts to unfair trade practice and deficiency in service.  So the opposite parties are legally bound to make payment for the treatment of the wife of the complainant and they are liable to pay compensation and cost of the proceedings to complainant. Hence the Commission finds that there is deficiency in service and unfair trade practice on the part of the opposite parties as alleged in the complaint. Hence we allow this complaint holding that opposite parties are deficient in service.

24.  We allow this complaint as follows:-

1. The opposite parties are directed to refund Rs.13,805/-(Rupees thirteen thousand  eight hundred and five only)  to the complainant,  the amount he had already spent for the treatment of  his wife.    
2. The opposite parties are directed to pay compensation of Rs. 20,000/- (Rupees Twenty thousand only) to the complainant on account of deficiency in service on the part of opposite parties and thereby caused mental agony, physical hardships and sufferings to the complainant.
3. The opposite parties are also directed to pay Rs. 2,000/- (Rupees Two thousand only) as cost of the proceedings.

         If the above said amount is not paid to the complainant within 30 days from the date of receipt of copy of this order, the opposite parties are liable to pay the interest at the rate of 12% per annum on the said amount from the date of receipt of the copy of this order till realisation.

Dated this 28^th day of November, 2023.

MOHANDASAN K., PRESIDENT

PREETHI SIVARAMAN C., MEMBER

MOHAMED ISMAYIL C.V., MEMBER

APPENDIX

Witness examined on the side of the complainant                        : Nil

Documents marked on the side of the complainant                      : Ext.A1to A7

Ext.A1 : Copy of repudiation of claim by opposite party dated 17/01/2023.

Ext.A2 : Copy of rejection and withdrawal of approval given earlier sent by  opposite

                parties  to the Korambayil hospital , Manjeri dated 25/11/2022. 

Ext.A3 : Copy of outpatient  record of complainant’s wife dated 17/11/2022(2 pages).

Ext.A4 : Copy of  patient information  dated 17/11/2022.

Ext.A5: Copy of  discharge bill  of complainant’s wife dated 24/11/2022.

Ext.A6: Series are the treatment bills of complainant’s wife. 

Ext.A7: Copy of  certificate given by Dr. Abussabah  regarding  the condition of    

              complainant’s wife. 

Witness examined on the side of the opposite party                      : Nil

Documents marked on the side of the opposite party                    : Ext. B1 to B5

Ext.B1 : Copy of  policy schedule and conditions .

Ext.B2 : Copy of request for cashless hospitalization from Korambayil hospital ,           

              Manjeri. 

Ext.B3 : Copy of   rejection of authorisation letter dated 24/11/2022.

Ext.B4 : Copy of discharge summary  from Korambayil hospital, Manjeri.

Ext.B5: Copy of repudiation letter dated 17/01/2023.

MOHANDASAN K., PRESIDENT

PREETHI SIVARAMAN C., MEMBER

MOHAMED ISMAYIL C.V., MEMBER

CPR