By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get reimbursement of hospital expenses from the opposite parties.
2. Brief of the complaint:- The complainant is the policy holder of opposite parties Medi classic Health Insurance policy vide No. P/181314/01/2013/006436 with effect from 31.03.2013 to 30.03.2014 for a sum assured up to Rs.50,000/-. Before the issuance of policy the complainant was medically examined and declared to be not suffering from any pre-existing diseases. The complainant admitted as an inpatient firstly at Leo Hospital, Kalpetta from 26.08.2013 to 29.08.2013 and then at MIMS, Kozhikode from 29.08.2013 to 08.09.2013 due to fever and cough. Then claim form submitted to reimburse the medical expense of Rs.1,26,800/- with all medical records and bills. But on 16.12.2013 complainant received a reply stating that this claim is rejected for the reason of “pre-existing disease”. Complainant alleges that he was not suffering from any such disease as alleged prior to the policy or later. Due to the said act of the opposite parties complainant suffered financial loss, mental agony and sufferings and filed this complainant to get reimbursement of the eligible amount with cost and compensation of this proceedings.
3. On being served, opposite parties entered and filed version. In the version, opposite parties admitted the policy and hospitalization of the complainant. They admitted that they have received a claim form with medical certificate, bills and lab reports in both claims. As per the discharge summary of Leo Hospital, Kalpetta the patient had history of LRTI, acute exacerbation with hypoxaemia for which he was treated with Oxygen inhalation, Bronchodilation and NIV. As the patient continued to have Hypoxaemia, he was referred to Medical College Hospital for further evaluation. The complainant thereafter on 29.08.2013 took admission at MIMS Hospital Kozhikode. In the discharge summary the final diagnosis recorded as Bronchopneumonia, Bronchial hyper reactivity & hypoxemic respiratory failure. Secondary diagnosis shows obstructive pulmonary disease. Again it was recorded that the patient had undergone HRCT Scan of Thorax shows that Panlobular emphysema with mild bronchiolectsis involving the right lung. Moreover course in the hospital column of discharge summary also reveals that the complainant had history of grade-1 dyspnea on exertion since 6 months as on date of admission 29.08.2013. Dyspnea means breathlessness. This means that the complainant was suffering from the symptoms from 29.02.2013. From the above treatment records, it is clear that the patient was suffering from the symptoms before the inception of policy (31.03.2013). Hence the claim falls under Exclusion Clause No.1 of the policy as pre-existing disease. Again opposite party submitted that even if the claim does not attract pre-existing disease clause it will definitely come under Exclusion No.2 of the policy ie 30 days waiting period. The contract of insurance is based on the principles of Uberime-fide and the proposer was duly bound to disclose every information sought through the proposal form and personal statement regarding his health history correctly. Hence the complainant has not revealed pre-existing illness in the policy and has tried to deframed the company by suppressing the facts but here in this case the complainant suppressed material facts relating to his health condition. Hence opposite party contented that there is no deficiency of service on the part of them.
4. On perusal of complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Relief and cost.
5. Point No.1:- Complainant field chief affidavit and examined as PW1, Exts.A1 to A3 and X1 series are marked. Opposite party also filed proof affidavit and examined as OPW1 and Exts.B1 to B10 were marked. Ext.A1 is the copy of Insurance Policy. Ext.A2 is the Repudiation letter dated16.12.2013. Complainant submitted two claim forms with relevant document to the opposite parties seeking reimbursement of the hospital expenses during 26.08.2013 -29.08.2013 and 29.08.2013-08.09.2013. According to the complainant the actual treatment expenses was Rs.1,26,500/-. But on 16.12.2013 complainant received a reply that claim for him rejected from opposite party's head office for the reason stating that “pre-existing disease”. Complainant stated that he was not suffering from such disease as alleged prior policy or later other than happened to be got ill and admitted in hospital. Due to the said acts from opposite parties complainant suffered financial loss, mental agony and sufferings. But opposite party argued that they have received the claim form and after receipt of claims made an investigation made an investigation & collected previous treatment records of the complainant from WIMS hospital, Wayanad. The copy of the case sheet dated 06.05.2013 reveals that the complainant was admitted with worsened dyspnea on exertion & cough since two weeks. Again it is stated that he had dyspnea on exertion grade 3-4 since 8 months. He has associated with cough & heartburn. The investigation shows PET (pulmonary function test) as very severe obstruction. The diagnosis recorded was severe COPD & Cor-Pulmonale. Cor Pulmonale is also known as Pulmonary heart disease. Chronic COPD is one of the cause for CorPulmonale. Based on the available medical records, the opposite party obtained an expert medical opinion which confirmed that the present treatment taken by the complainant was due to the complication of long standing Chronic Obstructive Pulmonary Disease (COPD). As the symptoms of Chronic Obstructive Pulmonary Disease ie, dysponea with exertion, cough with sputum production existed prior to the inception of the policy, the claim falls under Exclusion clause No.1 of the policy. Exclusion clause No.1 of the policy states that "Pre- Existing Disease as defined in the policy, until 48 months of continuance coverage have elapsed, since inception of the first policy with any Indian Insurance company". Moreover it is elaborately explained in the Definition clause of the policy that Pre-Existing Disease/ conditions means any ailments or injury or related condition( 5) for which the insured person had signs or symptoms and /or was diagnosed /or received medical advice treatment within 48 months prior to insured persons first policy with the company.
6. The claim falls under exclusion clause No.1 of the policy states that “pre-existing disease as defined in the policy until 48 months of continuance coverage have elapsed It is submitted that even if the claim does not attract pre-existing disease clause, it will definitely come under Exclusion Clause No.2 of the policy ie 30 days waiting period. Exclusion No.2 of the policy defines 30 days waiting period as "Any disease contracted by the insured person during the first 30 days from the commencement date of the policy". In this case the copy of the case sheet dated 06.05.2013 reveals that the complainant was admitted with worsened dyspnea on exertion & cough since two weeks as on 06.05.2013. This means that the onset of illness starts on 23.04.2013. This date (23.04.2013) comes within the 30 days waiting period (the policy starts from 31.03.2013). Hence both the claims 100835 and 103502 were rejected and the repudiation were informed to the complainant on 16.12.2013. The Complainant after receiving the repudiation letter from the Opposite Party had sent a lawyer notice on 23.01.2014 for which a detailed reply was sent by the Opposite Party. Hence denied the claim. The opposite party insurance company issued the policy on UTMOST GOOD FAITH. It is submitted that insurance contracts are “contracts of uberime-fide”. The opposite parties issued the aforesaid policy on good faith based on the declaration made by the proposer/insured in the proposal form that at the time of taking policy, complainant was subjected to preliminary medical examination which is only a routine checkup. If the insured person discloses the facts of pre-existing disease then he will be subjected to further medical examination to understand the seriousness of the pre-
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existing disease. Thereafter a decision will be taken on whether to accept or reject the proposal. But in this case the complainant has not informed about the pre-existing disease in the proposal form / at the time of medical examination. So he suppressed material facts of the pre-existing disease at the time of taking the policy. Punjab State Commission in 11 (2013) CPJ 89, held that even though the complainant/insured had taken medical examination & was declared fit for insurance, but this medical examination report is based on information supplied by the insured in the proposal form and before the doctor.
7. On going through the evidences and records this Forum finds that in Ext.B4 Discharge summary, treated Doctor stated that “There is history of Grade-1 dyspensa on exertion since six months”. But opposite party failed to produce any medical records or treatment records from any hospital showing that, the complainant's treated disease was a preexisting one. Findings shown in the Ext.B4 is only a presumption. If the possibility of this disease was there in this complainant, he has no knowledge about the same, no such disease or hospitalization was reported earlier. Again opposite party argued that the claim of this complainant definitely come under Exclusion clause No.2 of the policy defines 30 days waiting period as "Any disease contracted by the insured person during the first 30 days from the commencement date of the policy". But nothing is produced by opposite party to substantiate this. The policy is issued after a detailed medical check-up to rule out the existence of any diseases. Ext.B4(2) and (3) are the medical examination report of the complainant. The panel doctors of the company stated in this report that the patient is “Normal and Healthy”. In our opinion, there is no evidence of past history of treated disease to this complainant. Hence there is deficiency of service from the part of opposite parties.
8. Point No.2:- Since the Point No.1 is found in favour of complainant, he is entitled to get reimbursement of bill amount with cost and compensation.
In the result, the complaint is partly allowed and the opposite parties are jointly and severally liable to pay the the eligible amount as per the terms and conditions of the policy to the complainant without delay. They are also directed to pay Rs.2,000/- (Rupees Two Thousand) as compensation and Rs.2,000/- (Rupees Two Thousand) as cost of the proceedings. This Order must be complied by the opposite parties within 30 days from the date of receipt of this Order. On failure the complainant is entitled for interest at the rate of 12% per annum.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 23rd day of July 2015.
Date of Filing:26.03.2014.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
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PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Thomas. A. G. Complainant.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Claims Executive, Star Health.
Exhibits for the complainant:
A1. Copy of Medi classic Health Insurance Policy (Individual) Schedule.
A2. Repudiation Letter. Dt:16.12.2013.
A3(1). Copy of Lawyer Notice. Dt:23.01.2014.
A3(2). Postal Receipt.
A3(3). Postal Receipt.
A3(4). Acknowledgment Card.
A3(5). Acknowledgment Card.
X1 (Series). Claim Forms and medical documents submitted by the complainant to the
opposite parties.
Exhibits for the opposite parties:-
B1. Authorization Letter. Dt:25.03.2015.
B2. Medi classic Health Insurance Policy (Individual) Schedule.(4 pages).
B3. Copy of Discharge summary.
B4. Discharge Summary.
B5. Copy of Treatment Records (19 Pages).
B6. Copy of Repudiation Letter. Dt:16.12.2013.
B7. Lawyer Notice. Dt:23.01.2014.
B8. Copy of Reply Notice. Dt:08.05.2014.
B9. Proposal Form.
B10. Request for pre-under writing medical examination.(5 Pages).
Sd/-
PRESIDENT, CDRF, WAYANAD.
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