By Smt. Beena. M, Member:
This is a complaint preferred under Section 35 of the Consumer Protection Act 2019.
2. Brief facts of the complaint are as follows:-The Complainant took Family Health Optima Insurance Policy on 10.01.2014 by paying the premium of Rs. 4,607 for himself and for his family and the policy renewed without interruption. While the policy was in force, a wooden stick fell on the left wrist of the wife of the Complainant and fractured the bone and inserted steel rod. The Complainant incurred Rs.70,000/-, but the Opposite Party paid an amount of Rs.68,000/-as claim. Then on the basis of speaking with Opposite Party, the Complainant changed the policy which assured more sum and joined the scheme of Rs. 20,000/- as yearly premium. Prevailing old policy the Opposite Party allowed on 24.01.2021 to take new policy which coverage Rs.3,00,000/-. Thereafter, on 01.03.2022, the wife of the Complainant had undergone implant removal surgery at Vinayaka hospital, Sulthan Bathery and incurred expenses of Rs.41,921/- to the Complainant. Afterwards claim application given from the hospital to the Opposite Party, but they repudiated the claim. The Complainant paid the hospital bills by borrowing the money from his friend. The act of the Opposite Party is deficiency in service. Hence this Complaint.
3. Upon notice the Opposite Party appeared and filed version. It is admitted by the Opposite Party that the Complainant had taken Family Health Insurance Policy for the period from 25/11/2022 for a sum insured of Rs.3,00,000/-. At the time of issuing the policy, the terms and conditions were explained to the Complainant and the same was served to the Complainant along with the policy schedule. The company issued the policy to the Complainant based on the proposal form submitted by him. In the Proposal form, the Complainant has specifically declared that he was not suffering from any disease or ailment at the time of submitting the proposal form. After received the request for cashless hospitalization from Vinayaka hospital, the Opposite Party requested to forward previous discharge summary of radius fracture. The previous discharge summary dated 26/02/2021 forwarded by the hospital reveals that the Complainant’s wife was treated & diagnosed as fracture left radius and underwent ORIF under G A. So according to the Opposite Party the Complainant had history of fracture left radius which is prior to the inception of policy and was not revealed in the proposal form at the time of inception of policy. Hence it is pre- existing disease. The Opposite Party narrated the exclusion clause No.3 (1)(a) of the policy. It is submitted that after repudiated the cashless facility the Complainant has not approached the Opposite Party for reimbursement with original bills as per condition no. 4(2) (c) within 15 days. It is submitted that the Complainant had taken the policy on 10/01/2014 and the same has been renewed up to 08/02/2019. On 08/02/2019 the Complainant has not renewed the policy within the grace period of the policy and the policy was lapsed. Thereafter the Complainant had taken the policy as a fresh one after submission of online proposal form. The Complainant had suppressed the real facts. There is no deficiency in service /unfair trade practice on the part of Opposite Party. The Opposite Party prays to dismiss the complaint with compensatory cost.
4. The Complainant has filed proof affidavit in support of his claim and he is examined as PW1 and the documents produced marked as Ext. A1 to A3 and Ext. A4 is the confronted document and marked through OPW1. On the side of the Opposite Party Deputy Manager Legal filed proof affidavit and examined as OPW1 and documents produced were marked as Ext B1 to B6.
5. Based on the above averments and evidences, the points for consideration are:
- Whether there is any deficiency in service or unfair trade practice on the part of Opposite Party?
- If so what is the relief?
6. For the sake of convenience both issues are considered together. The allegation of the complainant is that the claim for treatment of expenses of the wife of the Complainant was repudiated by the Opposite Party due to the reason that the insured has failed to disclose about the wife of the Complainant has been suffering from radius since 22/02/2021, which is prior to inception of the first policy in proposal form. Ext A1 is the Family Health Optima Insurance Policy Schedule for the period from 10/01/2014 to 09/01/2015. The Opposite Party stated that the Complainant has been renewed the policy up to 08/02/2019. They further stated that the Complainant has not renewed the policy after 08/02/2019 and the Complainant had taken the policy as fresh one. Here the Complainant produced one document which is the print out of message sent by the Opposite Party to the Complainant. The document produced confronted to the OPW1 and marked as Ext A4, which shows that the Complainant renewed the above policy 25/11/2020 to 24/11/2021 and 25/11/2021 to 24/11/2022. As per Ext A4 it is also seen that the Complainant’s policy number is P/181315/01/2021/005299 and the first policy number is also mentioned as P/181315/01/2014/003248. When we peruse the documents it is so clear to see that after office code of the Opposite Parties i.e.181315 a number of 01 can be seen. So it can be inferred that the policy is a continuing policy from the first inception of policy. As per Ext. A1, it shows that the policy of the Complainant is commenced from 10/01/2014. The Opposite Party in his version stated that as per Exclusion clause 3(1)(a) of the policy which states that ‘’Pre-existing Disease as defined in the policy, the expenses related to the treatment of a pre-existing policy and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with us’’ It is already found that the policies mentioned above are continuing policy and it is also found that the inception of the policy is on 10/01/2014, it is so clear to find that the wife of the Complainant has not suffered any ailment until the expiry of 48 months. The Opposite Party stated in their version that the previous discharge summary reveals that the Complainant’s wife was treated as Communited (Fracture) Left Radius and underwent ORIF under GA. It is clear that the wife of the Complainant treated on 22/02/2021, it is after the 48 months of the inception of the first policy. When we perusing the cross examination of OPW1, he deposed that “Company ]cm-Xn-¡m-c\v Ab¨ message IfpsS print out BWv ImWn-¨Xv marked as Ext.A4”. In this case the Opposite Party has no case to see that the wife of the Complainant has not admitted in hospital or he has not spent any money for treatment. In the light of above finding, it is found that the policies are in continuing nature and the repudiation of the claim by Opposite Party is unjustifiable. Therefore, the Opposite Party committed deficiency in service, so they are liable to pay the claim amount with compensation and cost. Ext A3 shows that the Complainant had incurred an amount of Rs. 41,921/- for treatment. So he is entitled to get that amount.
In the result the complaint is partly allowed and the Opposite Party is directed to pay the claim amount of Rs.41,921/- (Rupees Forty One thousand Nine hundred and Twenty One only) with 6% interest from the date 03/03/2022 being the cost of the surgery with Rs.10,000/- (Rupees Ten thousand only) as compensation for deficiency in service and to pay Rs.5,000/- (Rupees Five thousand only) as cost of litigation. The above said amount shall be paid within one month from the date of receipt of this order. Failing which Complainant is entitled to get 8% interest for the above said amount from the date of order till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the day of 21st May 2024. Date of filing: 19.08.2022.
PRESIDENT: Sd/-
MEMBER: Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Vinod Kumar. K.V Complainant.
Witness for the Opposite Party:
OPW1. Balan. M. Deputy Manager- Legal.
Exhibits for the Complainant:
A1. Family Health Optima Insurance Policy – Schedule.
A2. Discharge Summary.
A3. Bill. dt:03.03.2022 .
A4. Print out of Message.
Exhibits for the Opposite Party:
B1. Copy of Letter. dt:25.11.2021.
B2. Copy of Proposal Form.
B3. Copy of Request for cashless Hospitalisation for Health Insurance.
B4. Copy of Query on Authorization for Cashless Treatment. dt:01.03.2022.
B5. Copy of Discharge Summary.
B6. Copy of Letter. dt:03.03.2022.
PRESIDENT: Sd/-
MEMBER : Sd/-
