By Sri. MOHANDASAN.K, PRESIDENT
Case of the complainant is as follows:-
1. The complainant subscribed the policy of Religare Health Insurance Company as per policy No.12279898 which is valid from 24/03/2018 to 23/03/2021. As per the insurance policy the complainant and his wife stands covered. The complainant remitted premium of Rs.45,096/- and he was served with policy certificate on 10/04/2018. But while the policy was in force an agent of the opposite party namely Mr. Sethumadavan, intermediary code No. BA 0000076939 approached the complainant and requested the complainant to port his policy in to the opposite party company and offered that they will provide more benefits to the complainant and his family. The complainant received the offer from the opposite parties on 13/03/2021.
2. On 13/03/2021 the complainant was served with proposal form of the opposite party and he renewed his present insurance policy with the opposite party from the date of 24/03/2021 to 23/03/2022, as per the policy No.P/181323/01/2021/004385. The complainant remitted 21,349/- rupees towards the premium on 14/03/2021.
3. Meanwhile the complainant happened to suffer pain to abdomen and he was taken to the KIMS Alshifa Hospital Perinthalmanna on 04/10/2021 and he was examined by Dr. Saju Xavier. He underwent more medical examination and as per the result of the examination he was referred to Amrita Institute of Medical Science Kochi and he got admitted therein on 31/10/2021. On examination from the Amrita hospital on 02/11/2021 it was revealed (1) Moderately differentiated adenocarcinoma of assenting colon (2) margin is free from tumor. The complainant underwent treatment there in up to 06/11/2021. The complainant had undergone treatments for purely differentiate adenocarcinoma, synchronous polyps (2. In rectum 1 in transverse colon) Adenomatous polyps with low grade dysplasia in the hospital for the diagnosed ailments. The complainant continuing Chemotherapy at present.
4. The complainant submitted the insurance details to the hospital at the time of admission itself with the purpose of availing cash less treatment facility, but the opposite party denied the same. The complainant submit that the opposite party denied the claim alleging pre-existing aliment that the complainant suppressed the fact he was suffering the ailment prior to the inception of policy. The complainant alleges the opposite party blamed the complainant who was the policy holder of Religare insurance company for a long period. The complainant was communicated the repudiation information only on 07/03/2022. The complainant submitted that he spent more than 3 lakh rupees for the treatment but the opposite party denied the insurance claim and also delayed the communication of repudiation of claim. The act caused mental and physical hardship to the complainant. The complainant submits that he was never suffering from any disease while incepting the policy of the opposite party. If it was any sort of pre-existing ailment, the complainant would not have ported the insurance coverage from Religare insurance company to the opposite party insurance company. The complainant submits that he could diagnose the ailment only during the October-November months of 2021. The complainant underwent medical checkup for the present ailment only on 22/10/2021. Thereafter the investigations confirmed the ailment and he was taken to lakeshore hospital for the treatment under Dr. Gangadharan and in the Kochi IndiraGandhi co-operative hospital. The complainant submit that the opposite party repudiated the claim solely because of the treatment note obtained from Dr. Dinesh Balakrishnan attached to Amritha institute of medical science, Kochi. But the Doctor. Subsequently issued a letter stating that it was his mistake while noting the history of treatment in the relevant medical record. The complainant submitted the letter issued by Dr. Dinesh Balakrishnan which reads as follows “Patient was seen by me in OPD. He mentioned about an episode of pain one year back. During documentation, I have put it down “since “one year. This has resulted in the claim being denied. I must admit this is unfortunate. The patient had recent episodes of tiredness which was due to anemia. Evaluation of this lead to the diagnosis. Please feel free to contact me if you need any further clarification “.
5. The complainant submitted that the Dr, Dinesh Balakrishnan treated the complainant very well but misleading the doctor the opposite party obtained information and thereby denied the genuine claim of the complainant which is bad and cheating. The complainant is a policy holder of the health insurance which he subscribed not due to any ailment. The complainant has not suppressed any true facts as alleged by the opposite party. There cannot be any records of treatment prior to the inception of health policy.
6. The agent of the first opposite party approached the complainant and made believe the opposite party is more trustworthy and beneficial comparing to Religare insurance company and thus the complainant ported to the policy of the opposite party on 13/03/2021, till that day he was holding a policy with the Religare insurance company from 24/03/2021 to 23/03/2022. The complainant alleges that the act of the opposite party amounts unfair trade practice and there is deficiency in service on the part of the opposite party. Hence, the complainant claims compensation of Rs.10,00,000/- along with treatment expenses of Rs.5 lakhs and cost of the complaint as 25,000/-.
7. On admission of the complaint notice was issued to the opposite parties and the opposite parties entered appearance and filed version denying the entire averments and allegations in the complaint.
8. The opposite parties admitted that the complainant had taken a policy under the name family health optima insurance plan for the period commencing from 24/03/2021 to 23/03/2022 for a sum of Rs.5,00,000/- vide policy No.P/181323/01/2021/004385. The complainant submitted proposal form and revealed that his previous insurance details with Religare health insurance from 24/03/2018 and also recorded that he was not suffering from any pre-existing disease .
9. At the time of availing the policy the complainant was supplied with the terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to them along with the policy schedule. It was clearly stated in the policy schedule that “the insurance under this policy is subject to condition, clauses, warranties, and exclusions etc, attached“.
10. The opposite party submitted that during the aforesaid policy period the oppose parties had received a request for cash less treatment from Amirtha Institute of Medical sciences, Ernakulum stating that the complainant was admitted at the hospital on 31/10/2021 and was provisionally diagnosed with ascending colon polyp in the authorization request the treating doctor had noted the duration of the present ailment as one year. Based on the duration mentioned in the pre authorization request, the opposite parties issued a query letter dated 26/10/2021 directing the hospital to submit the exact duration of present ailment with first consultation papers and treatment record taken since diagnosed. But the hospital and the complainant has not forwarded any documents as sought for by the opposite parties. Based on the duration mentioned in pre authorization request it is revealed that the complainant has been suffering from the condition for the last one year which is prior to the inception of star health and ailed insurance policy. So it is a pre existing disease and the opposite parties rejected the authorization for cash less treatment vide letter dated 29/10/2021 and informed the hospital and the complainant. The complainant discharged from the hospital and submitted claim form along with discharge summary and bills of Rs.2,44,312/- only. As per the request for cash less request form issued by the hospital it is clear that the complainant has been suffering the present decease for the past one year. In order to process further the opposite parties issued a query letter dated 23/12/2021 directing the complainant to provide past one year consultation / treatment details pertaining to present ailment.
11. The opposite party submitted that the complainant had submitted consultation records from Dr. Saju Xavier, KIMS Alshifa hospital dated 04/08/2020,20/08/2020 and 12/09/2020 which clearly states that the complainant had history of abdominal pain since one year. The opposite party submitted that as per available medical records the insured person had history abdominal pain since one year i.e before the inception of the policy with the opposite parties but the same was not discussed in the proposal form at the time of inception of policy. The opposite party submitted the complainant had willfully suppressed the pre-existing disease and its treatment details in the proposal form, which is the basis of contract at the time of taking the policy, it amounts suppression of material fact. Considering the fact, the opposite party repudiated the claim as per the terms and conditions of the policy and the same was communicated to the complainant by letter dated 08/02/2022.
12. There after the complainant had submitted a representation to the opposite parties to consider the claim and on the basis of the request the opposite parties reopened the file and sought an expert opinion. Based on the advice of the expert the opposite party had processed the claim as per the terms and conditions of the policy and found that the payable amount will comes to Rs.1,84,231/- from the total bill amount of Rs.2,44,312/-. The opposite parties credited the said amount of Rs.1,84,231/- to the account of the complainant on 07/04/2022. It is further submitted that the privity of contract between the parties came to an end the moment the complainant had accepted the claim payment unconditionally. The allegation of the complainant that he had incurred an amount of Res.30,0000/-as treatment expenses are not correct. The complainant had only submitted a claim of Rs.2,44,312/-. The opposite party denied that the complainant suffered physical, mental, financial agony due to the act of the opposite parties. The opposite party approved the claim of the complainant and allowed Rs.1,84,231/- which is the maximum amount payable as per the terms and conditions of the policy . So there is no unfair trade practice or deficiency of service from the part of the opposite parties as the opposite party is as duly paid the full amount to the complainant. The complainant is not entitled for Rs.10 lakh being the compensation for the mental agony and also the complainant is not entitled to Rs. 25,000/- being the cost of the proceedings. The complainant has not raised any objection whatsoever after receiving the amount accepted the same. The complainant is not entitled for any of the relief mentioned in the complaint. There is no cause of action for the complainant as the opposite parties had paid the amount to the complainant as per the terms and conditions of the policy. Hence, the complaint is liable to be dismissed accepting the version of the opposite party.
13. The complainant and opposite parties filed affidavit and documents. The documents on the side of complainant marked Ext. A1 to A11 series. Ext. A1 is copy of policy certificate dated 10/04/2018, policy No.12279898. Ext. A2 is copy of policy certificate issued by star health and allied insurance company limited dated 14/03/2021. Ext. A3 is copy of colonoscopy dated 21/10/2021, Alshifa hospital Perinthalmanna. Ext. A4 is copy of colonoscopy biopsy report dated 21/10/2021, Alshifa hospital Perinahtalmman. Ext. A5 is copy of discharge summary dated 06/11/2021, Amritha institute of medical science Kochi. Ext. A6 is copy of discharge summary dated 06/11/2021, Amritha institute of Medical Science Kochi. Ext. A7 copy of surgical pathology report dated 30/11/, Lakeshore hospital Koch. Ext.A8 is copy of treatment certificate dated 10/11/2021, issued Amritha institute of medical Science Kochi. Ext. A9 is copy of letter issued by Star health and allied insurance company limited to the complainant dated 22/12/2021. Ext. A10 is repudiation letter issued by Star health and allied insurance company limited to the complainant dated 08/02/2022. Ext. A11 series are bills obtained from Indira Gandhi co-operative hospital and other treatment centers where in the complainant undergone treatment. The documents on the side of opposite party marked as Ext. B1 to B14. Ext. B1 is copy of policy schedule and conditions issued by the star and allied health insurance Company dated 14/03/2021. Ext. B2 is original proposal form dated 09/03/ 2021. Ext. B3 is copy of request for cashless hospitalization for health insurance presented through Amritha institute of medical science. Ext. B4 is copy of query on authorization for cashless treatment dated 26/10/2021. Ext. B5 copy of rejection of authorization for cashless treatment dated 29/10/2021. Ext.B6 is copy of discharge summary issued from Amritha institute of medical Science, Ernakulum dated 06/11/2021. Ext. B7 copy of query letter dated 23/12/2021 issued by the star health and allied insurance company Ext. B8 copy of consultation records from Dr. Saju Xavier, Alshifa hospital Perintahalmann dated 04/08/2020,20/08/2020 and 12/08/2020. Ext. B9 is copy of representation submitted by the complainant before the star health insurance dated 12/04/2022. Ext. B10 copy of payment voucher for Rs.184231/- dated 07/04/2022. Ext.B11 is copy of representation submitted by the complainant before the opposite party dated 12/04/2022. Ext.B12 is copy of query letter dated 10/06/2022 issued by the star health and allied insurance company. Ext. B13 is copy of replay submitted by the complainant along with breakup details and lab report. Ext. B14 is copy of payment voucher for Rs.33,340/- dated 0907/2022.
14. Heard the parties, perused affidavit, and documents. The complainant filed argument note also.
The following points arise for consideration: -
- Whether there is deficiency in service and unfair trade practice on the part of the opposite parties
- Whether the repudiation of the claim of the complainant is justifiable or not?
- Whether the complainant is entitled for the inseunce coverage during the period of his treatment?
- Whether the complainant is entitled for compensation and cost?
15. Point No.1 and 2
The complainant herein filed this complaint on 16/03/2022 alleging the repudiation of the claim of the complainant by the opposite party. The complainant produced Ext. A10 the letter of repudiation issued by the opposite party dated 08/02/2022. The letter of repudiation Ext. A10 averred as follows: “…….. We have processed the claim records relating to the above insured person seeking re imbursement of hospitalization expenses for treatment of above said diagnosis.
Suppression of material fact: - it is observed form the medical reports that the insured person had history of abdominal pain since one year which is prior to inception of star health medical insurance policy.
At the time of inception of star health insurance policy which is from 24/03/2021 to 23/01/2022, you have not disclosed the above mentioned medical history / health details of the insured person in the proposal form which amounts to misrepresentation / non disclosure of material facts.
As per condition No.5 (6) of the policy issued to you, if there is any misrepresentation / non disclosure of material fact whether by the insured person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim .
We are there for unable to settle your claim under the above policy and we here by repudiate your claim.
As per condition No.5 (10) the renewal policy is also liable to be cancelled and necessary action will be taken by our corporate office.
The above decisions are taken as per the terms and conditions of the policy and based on the claim details / documents submitted
We are always at your service …….”
16. The Ext. A10 caused filing the present complaint. The opposite parties submitted version on 18/07/2022, admitting the subscription of policy by the complainant as per the policy, it is valid from 24/03/2021 to 23/03/2022, assuring Rs.5,00,000/- and the policy is No.P/181323/01/2021/004385. The opposite party further admitted that the complainant submitted request for cashless treatment through Amritha Institute of medical sciences. In the authorization from the hospital the treating doctor of the complainant had noted the duration of the present ailment as one year. Then the opposite party issued a query letter dated 26/10/2021 directing the hospital to submit the exact duration of present ailment along with consultation papers and treatment record taken since diagnosed. The opposite party submitted that neither the hospital nor the complainant forwarded any documents as sought for by the opposite parties. Hence, considering the fact that the complainant was suffering from the conditions for the last one year which is prior to inception of star health and allied insurance policy and it was treated as pre-existing disease, the opposite parties rejected the authorization for cashless treatment. Thereafter discharge from the hospital, the complainant submitted claim form along with discharge summary and bill of Rs.2,44,312/-. The opposite party again issued a query letter dated 23/12/2021 directing the complainant to provide past one year consultation / treatment details pertaining to present ailment. The treatment records submitted by the complainant obtained from Alshifa hospital 04/08/2020, 20/08/2020, 12/09/2020 clearly stated that the complainant had history of abdominal pain for one year. Hence, the opposite party repudiated the claim of the complainant as per terms and conditions. But thereafter the complainant had submitted representation to the opposite party requesting to reconsider his claim. Then the opposite parities reopened the file and sought an expert opinion. On the basis of advice of the expert the opposite party had processed the claim as per the terms and conditions of the policy and found that the payable amount will comes Rs.1,84,231/- from the total bill of Rs.2,44,312/-and the opposite party credited the said amount to the account of the complainant on 07/04/2022. The submission of the opposite party is that the privity of contract between parties, if any came to an end the moment the complainant had accept the claim payment unconditionally . Hence the contention of the complainant is that the opposite party initially repudiated the claim based on the treatment records and thereafter on the request of the complainant had approved the claim the claim for Rs.1,84231/- which is the maximum payable amount as per the terms and conditions of the policy. Hence the contention is there is no unfair trade practice or deficiency of service from the part of the opposite parties as the opposite parties had duly paid the full amount to the complainant.
17. The perusal of the document reveals that the opposite party initially repudiated the claim holding pre-existing decease while incepting the insurance policy. The complainant produced Ext. A8 issued by Dr. Dinesh Balakrishnan of Amrita Institute of medical sciences dated 10/11/2021 which reads as follows: -“patient was seen by me in OPD. He mentioned about an episode of pain one years back. During documentation, I have put it down “since “one year. This has resulted in the claim being denied. I must admit that this is unfortunate. The patient had recent episodes of tiredness which was due to anemia. Evaluation of this lead to the diagnosis. Please feel free to contact me if you need any further clarification.” The letter issued by the doctor dated 10/11/2021 rightly revealed what happened to assess pre-existing decease to the complainant and thereby repudiating the claim of the complainant. The date of Ext. A8 is important one, which is 10/11/2021. But the opposite party issued repudiation letter to the complainant on 08/02/2022. So it can be see that the opposite party without considering the Ext. A8 document issued repudiation letter after few months. But it can be seen that the opposite party on request from the complainant approved the claim for Rs.1,84,231/- against the claim amount of Rs.2,44,312/- which is the maximum payable amount as per the terms and conditions of the policy, according to opposite party and that was credited in favor of the complainant on 07/04/2022. Thereafter on 11/07/2022 an amount of Rs.34,340/- and thereafter on 03/08/2022 an amount of Rs.45340/- also credited in favor of the complainant. All these amounts were allowed in favor of the complainant after filing this complaint. The case of the complainant is that the complaint submitted bills worth Rs. 3,93,366/- and out of the same an amount of Rs.2,62,885/- has been allowed by the opposite party . The complainant prays for the balance amount of Rs.1,30,481/- from the opposite party. Ext. A11 series are the medical bills produced by the complainant in support of his claim. The perusal of the bills that is Ext. A11 series substantiate the claim amount of the complainant. Hence, we find that there is deficiency in service and unfair trade practice from the side of opposite party and the complainant is entitled the medical expenses of Rs.1,30,481/- claimed by the complainant.
18. Point No.3 and 4
The documents produced by the complainant shows that he was having insurance policy of Religare health insurance for the period 24/03/2018 to 23/03/2021. The complainant was influenced by the opposite party man and the complainant shifted his insurance policy to the opposite party from 24/03/2021 up to 23/03/2022. The complainant remitted his insurance premium to the opposite party as per invoice dated 14/03/2021 i.e 10 days prior to the existing policy of the complainant with the Religare health insurance. But the opposite party recorded that date of inception of first policy as 24/03/2021. So we find that the attitude of the opposite party is not fair one and amounts gross deficiency in service. The reason for repudiation of claim is that the complainant suppressed history of illness of one year at the time of subscribing the policy of opposite party. But the complainant had a valid policy from 2018 onwards and it was in force at the time of subscribing policy of the opposite party. Moreover, the complainant herein submitted for the cashless facility from the opposite party, but the opposite party denied the same without looking in to the genuineness of the claim of complainant. It is evident that the complainant was undergoing treatment for the capital ailment which causes much pain and hardship to the complainant. The legitimate claim of the complainant stands rejected without valid cause. The act of the opposite party resulted mental agony, physical as well as financial difficulty to the complaint and for which the opposite party is liable to pay reasonable amount as compensation. The commission consider Rs.1,50,000/- as reasonable amount towards the compensation on account of unfair trade practice, deficiency in service and thereby caused inconvenience, hardship, mental agony and financial loss sustained by the complainant. The complainant is also entitled an amount of Rs.10,000/-as cost of the proceedings.
In the light of above fact and circumstances we allow this complaint as follows:-
- The opposite parties are directed to pay Rs.1,30,481/- (Rupees one lakh thirty thousand four hundred and eighty-one only) to the complainant on account of the treatment expenses .
- The opposite parties are directed to pay Rs.1,50,000/- (Rupees one lakh fifty thousand only) as compensation to the complainant on account of deficiency in service and unfair trade practice from the side of opposite party and thereby caused inconvenience, hardship, mental agony and financial loss sustained by the complainant .
- The oppose parties are directed to pay Rs.10,000/- (Rupees Ten thousand only) as cost of the proceedings to the complainant .
The opposite parties are liable to complaint this order within one month from the date of receipt of copy of this order failing which the complainant is entitled interest at the rate of 9% per annum for the above entire amount till date of payment .
Dated this 13th day of June , 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.A1 to A11
Ext.A1: Copy of policy certificate dated 10/04/2018 policy No.12279898.
Ext.A2: Copy of policy certificate issued by star health and allied insurance company
limited for the period 2021 to 2022 dated 14/03/2021.
Ext A3: Copy of colonoscopy dated 21/10/2021 Alshifa hospital Perinthalmanna.
Ext A4: Copy of colonoscopy biopsy report dated 21/10/2021 Alshifa hospital
perinahtalmman .
Ext A5: copy of discharge summary date d06/11/2021 Amirtha institute of medical
science Kochi .
Ext.A6: Copy of discharge summary Amirtha institute of Medical Science Kochi.
dated 06/11/2021
Ext.A7: Copy of surgical pathology report dated 30/11/ Lakshor hospital Koch.
Ext.A8: copy of treatment certificate issued by dated 10/11/2021 Amirtha institute o
medical Science Kochi..
Ext.A9: Copy of letter issued by Star health and allied insurance company limited to
the complainant dated 22/12/2021.
Ext.A10: Rrepudiation letter issued by Star health and allied inseunce company
limited to the complainant dated 08/02/2022.
Ext.A11: (series) are bills obtained from Indira Gandhi co operative hospital and other
treatment centers were in the complainant undergone treatment Kadvanthra
Kochi.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B14
Ext.B1: Copy of policy schedule and conditions issued by the star and allied health
insurance Company dated 14/03/2021.
Ext.B2: Original proposal form dated 09/03/ 2021
Ext.B3: Copy of request for cashless hospitalization for health insurance presented
through Amirthaa institute of medical science.
Ext.B4: Copy of query on authorization for cashless treatment dated 26/10/2021.
Ext.B5: Copy of rejection of authorization for cashless treatment dated 29/10/2021.
Ext.B6: copy of discharge summary issued from Amirtha institute of medical Science
Ernakulum dated 06/11/2021.
Ext.B7: Copy of query letter dated 23/12/2021 issued by the star health and allied
insurance company
Ext.B8: Copy of consultation records from Dr. Saju Xavier, Alshifa hospital
perintahalmann dated 04/08/2020,20/08/2020 and 12/08/2020.
Ext.B9: Copy of representation submitted by the complainant before the star health
insurance dated 12/04/2022.
Ext.B10: Copy of payment voucher for Rs.184231 dated 07/04/2022.
Ext.B11: Copy of representation submitted by the complainant before the opposite
party dated 12/04/2022.
Ext.B12: Copy of query letter dated 10/06/2022 issued by the star health and allied
insurance company.
Ext.A13: Copy of replay submitted by the complainant along with breakup details and
lab report.
Ext.B14: Copy of payment voucher for Rs.33,340/- dated 0907/2022.
Mohandasan . K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
VPH
