By. Smt. Beena. M, Member:-
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Brief facts of the complaint:- The Complainant had taken a mediclaim policy named Family Health Optima Insurance plan from Opposite Party No.1 on 29.06.2012 for the sum assured Rs.3,00,000/-. It was a floater policy covering the Complainant and his wife. It was renewed from time to time. The Complainant submitted that the policy amount was enhanced from Rs. 3,00,000/- to Rs.5,00,000/- w.e.f 12.07.2021 and the Complainant paid the premium amount of Rs.16,524/-. The policy covered the Complainant, his wife and children. The bonus amount received by the Complainant was added to the sum assured and the total sum insured was Rs.5,60,000/-. The said policy was again renewed on 12.07.2022, which was valid for period from 12.07.2022 to 11.07.2023. Subsequently, on 22.08.2021, the Complainant consulted casualty medical officer of Leo Hospital, Kalpetta with complaints of muscle pain below the chest and discomfort while sneezing. Since the pain did not subside, the Complainant consulted various doctors in Kerala and Tamilnadu. Finally in the month of October 2021, it was confirmed from Christian Medical College, Vellur, that the Complainant was suffering from Multiple Myloma, a type of cancer. The Complainant was treated at MVR cancer institute Kozhikode and Christian medical college Vellur. As per the advice of the doctors of Christian Medical College, the Stem Cell Therapy was done in the second week of April 2022. Thereafter, the pre authorization request for cashless treatment was given to the Opposite Party. The Opposite Party approved only 75,000. Then the Complainant submitted an application for enhancement of cashless treatment to the Opposite Party. But the Opposite Party rejected the request on the ground that ‘maximum amount eligible as per sublimit for bone marrow implantation has already been exhausted’. Thereafter, another round of stem cell therapy was done on 11.08.2022. This time also the respondent approved only Rs.75,000/- and the request for enhancement of amount for cashless treatment was rejected for the same reason. According to the Complainant, he is entitled to get cashless treatment up to Rs.2,50,000/- for each stem cell therapy as per Clause Y of the terms and conditions of the policy, where the sum insured is Rs.5,00,000/-. Rejection of the request for enhancement constrained the Complainant to pay the balance amount of Rs.3,50,000/- to the hospital. It caused much difficulty to the Complainant. The act of Opposite Party amounts to deficiency in service and unfair trade practice. Due to this, the Complainant has suffered loss, hardship, agony and damage. Hence, this Complaint.
3. After the admission of the Complaint, Commission issued summons to the Opposite Parties. The Opposite Parties entered appearance and filed version stating the following contentions.
4. The Opposite Party submitted that the Complainant had purchased the medi claim policy, firstly on 20.06.2012 for a sum of Rs.2,00,000/-. Thereafter, he changed Medi Classic Health Insurance Policy to Family Health Optima Insurance Policy on 12/07/2013 and it was renewed successively up to 11.07.2019 for Rs.2,00,000/-. Thereafter, the Complainant enhanced the sum assured from Rs.2,00,000/- to Rs.3,00,000/-on 12/07/2019 and it was again renewed upto 11.07.2021. Thereafter, he again enhanced the sum insured from 3,00,000/- to 5,00,000/-for the period from 12.07.2021 to 11.07.2022 and the same was renewed up to 11.07.2022 and the same has been renewed up to 11.07.2023. 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. It is submitted that as per condition Clause No.5(20) (Enhancement of sum insured) of the policy it is stated that where the sum insured is enhanced, the amount of such additional sum insured (including the respective sub limit) shall be to the following terms;-
5. Exclusion as under shall apply afresh from the date of such enhancement for the increase in the sum insured, that is, the difference between the expiring policy sum insured, and increased sum insured. 1) First 30 days as under Exclusion code Excl 03. 2) 24 months with continuous coverage without break (with grace period) in respect of Pre Existing diseases Code Excl 02. 3) 48 months of continuous coverage without break (with grace period) in respect of pre-existing disease code Excl 01. 4) 48 months of continuous coverage without break (with grace period) for diseases/ conditions diagnosed/ treated irrespective of whether any claim is made or not in the immediately preceding three policy period. It is submitted that in first claim the Opposite Party had received a request for cashless treatment from Christian Medical College Vellore, Tamil Nadu stating that the Complainant was admitted on 12/04/ 2022 for the treatment of Multiple Myeloma and underwent Antologous Stem cell transplant. After receiving the request form, the Opposite Party had initially authorized an amount of Rs. 75,000/- and the same was informed to the Complainant and the hospital authority on 18.04.2022. After the treatment, the hospital authority had forwarded the discharge summary along with final bill of Rs.6,25,925/-. It is submitted that after verified the discharge summary dated 24/10/2021 issued by Meitra Hospital Calicut reveals that the Complainant had history of Multiple Bony pains since 6 months and diagnosed as Multiple Myeloma (61% Plasma cells). This means that the present condition as suffered on 24.06.2021 and this date comes within the policy period from 12.07.2021 to 11.07.2021 for a sum insured of Rs.3,00,000/-. It is submitted that as per special condition for modern treatment clause of the terms and conditions of the policy, the expenses payable during the entire policy period for the Stem Cell Therapy: (Hematopoietic stem cells for bone marrow transplant for hematological conditions) is limited to Rs.75,000/- for a sum insured of Rs.3,00,000/-. Based on the terms and conditions of the policy, the Opposite Parties had informed to the Complainant and the hospital authority that they had approved Rs.75,000/- on 18.04.2022 for treatment of the above diagnosed disease. The maximum amount eligible as per the sub limit for stem cell therapy has already been exhausted and rejection letter was forwarded to the Complainant and the Hospital authority on 02.05.2022. After discharge from the hospital, the Complainant had submitted the claim form and other related documents for reimbursement and after verification of the records it is seen that the maximum sub-limit is already exhausted. Hence the Opposite Parties had repudiated the claim and the same was informed to the Complainant on 17.05.2022. It is submitted that in second claim, during the policy period from 12.072022 to 11.07.2023, the Opposite Parties had received a request for cashless treatment from Christian Medical College Vellore, Tamilnadu stating that the Complainant was admitted on 08.08.2022 for the treatment of Myloma for transplant and underwent Bone Marrow transplant. After receiving the request form, the Opposite Party had initially authorized an amount of Rs.75,000/- and the same was informed to the Complainant and the hospital authority on 11.08.2022. After the treatment, the hospital authority had forwarded the discharge summary along with final bill of Rs.4,24,999/-. Based on the first claim details, the Opposite Parties had processed the claim as per special condition for modern treatment clause of the terms and conditions of the policy, the expenses payable during the entire policy period for the Stem Cell Therapy: (Hematopoietic stem cells for bone marrow transplant for hematological conditions) is limited to Rs.75,000/- for a sum of Rs.3,00,000/-. Based on the terms and conditions of the policy, the Opposite Parties had informed to the Complainant and the hospital authority that Rs.75,000/- was approved on 11.08.2022 for treatment of the above diagnosed disease. The maximum amount eligible as per the sub limit for bone marrow transplant has already been exhausted and rejection letter was forwarded to the Complainant and the hospital authority on 25.08.2022. The Opposite Party further submitted that the Complainant has only availed cashless facility and after discharge from the Hospital no additional bills/ documents were submitted before the Opposite Parties for reimbursement. The Opposite Party had acted as per terms and conditions of the policy. So there is no deficiency in service on the part of the Opposite Parties. Therefore, the Opposite Party prayed for the dismissal of the Complaint.
6. On perusal of the Complaint, Version and documents, Commission raised the following points for Consideration:-
- Whether there is any deficiency in service from the part of Opposite Party?
- Whether the Complainant is entitled to get any relieves as prayed for?
7. Point No. 1 and 2 :- For the sake of convenience and brevity all the points are considered together.
The Complainant had filed proof affidavit and he was examined as PW1 and documents produced were marked as Ext. A1 to A7 series marked. No oral evidence for the Opposite Party, the document produced was marked as Ext. B1.
8. Heard the arguments from both parties.
9. The complaint filed is for payment of claim amount of the medi claim policy towards medical expenses for Rs.3,50,000/-. The Complainant’s main case is that the Complainant had enhanced the policy amount to Rs.5,00,000/- from Rs.3,00,000/- and for that he claimed Rs.3,50,000/- towards medical expenses for his treatment in the Christian Medical College, Vellur on 24.10.2021 and discharged on 26.10.2021. On the other hand the Opposite Parties disputing with the plea that as per Clause 5(20) of policy condition, 1. First 30 days as under Exclusion Code EXCL 03. In the present Complaint it is seen that the Complainant had taken the policy on 12/07/2022. Excl. 1) the Complainant is not entitled to get the benefit of enhancement before 48 months. It is true that the Complainant was admitted and spent the amount for his treatment before 48 months of the enhancement of the policy amount, but the main question is whether this enhancement of policy amount is the continuation of policy or fresh policy. If it is a fresh policy as per Clause 5 (20), we can conclude that the Complainant is not entitled to get the benefit of enhancement policy. Considering the materials on record we are of the view that admittedly the Complainant is an old policy holder and there is no discontinuation of policy and with the proposal of the benefit of enhanced policy to Rs.5,00,000/- and as such, the Complainant is entitled to get the benefit of the enhanced policy of Rs.5,00,000/-. As per the version filed by the Opposite Party it is seen that (para 6) the hospital authority forwarded the discharge summary along with bill of Rs.6,25,925/-. Hence after deducting the amount of Rs.1,50,000/- paid by the Opposite Party towards the treatment, the Complainant is entitled to get the balance amount of Rs.3,50,000/-. Due to the wrong refusal of the claim, the Complainant ought to have undergone mental agony and the Complainant is entitled to get compensation and cost of the proceedings.
In the result Complaint is partly allowed as follows:-
The Opposite Parties are jointly and severally, directed to pay Rs.3,50,000/-(Rupees Three Lakh Fifty Thousand only) towards balance medical expenses, Rs.10,000/-(Rupees Ten Thousand only) as compensation and Rs.8,000/-(Rupees Eight Thousand Only) as cost of the proceedings.
The above said amount shall be paid within one month from the date of receipt of this order. Failing which the Complainant is entitled to get 8% interest from the date of this order till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 16th day of December 2023.
Date of Filing:-07.12.2022.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Anseer. E. H. Business.
Witness for the Opposite Parties:-
Nil.
Exhibits for the Complainant:-
A1(Series). Copy of Family Health Optima Insurance Plan (9 Pages).
A2. Copy of Cashless Authorization Letter. Dt:30.04.2022.
A3. Copy of Rejection of Request for enhancement of amount for
cashless treatment. Dt:02.05.2022.
A4. Claim Repudiation Letter. Dt:17.05.2022.
A5. Cashless Authorization Letter. Dt:11.08.2022.
A6. Copy of Rejection of Request for enhancement of amount for
cashless treatment. Dt:25.08.2022.
A7(Series). Copy of Treatment Records of Complainant from Leo Hospital,
Kalpetta (21 Pages).
Exhibits for the Opposite Parties:-
B1. Customer Information Sheet, Family Health Optima Insurance
Plan.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
