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 the claim amount from opposite parties.
2. Brief of the complaint:- The complainant is the policy holder of the Family Health Optima Insurance Policy conducted by the opposite parties. The complainant is holding the policy from -2008 onwards without any interruption. Originally the complainant was the holder of the Family Insurance Policy of United India Insurance Co. ltd, and in the year 2013 he has ported the policy with the opposite parties. The complainant has paid an amount of Rs.6,371/- towards the premium covering one adult and three children i.e., the wife and three children of the complainant, up to the coverage of Rs.3,00,000/- and the opposite party has issued policy in No. P/181315/O1/2014/OO1126 which is having the validity from 23.07.2013 to 22.07.2014. During the previous policy period the wife of the complainant had undergone a surgery for bilateral ovarian cyst at Vinayaka Hospital, Sulthan Bathery in September 2012. The complainant had disclosed the previous surgery to the opposite party while he is porting to the present policy and the opposite party has recorded the details in the policy. Even after the surgery cyst was again found and so she had to undergone treatment at Baby memorial Hospital, Kozhikode were also another surgery is done to remove the cyst. The matter of hospitalization was duly intimated to the opposite party at the time of admission itself and the agent of the opposite party has visited the patient at the Hospital. The agent has informed the complainant that the complainant himself has to pay the hospital bills since the opposite party has no tie up with the treating Hospital ie Baby Memorial Hospital, Kozhikode. So the complainant had paid the bills for the amount of Rs.71,896/- and subsequently approached the opposite party for the reimbursement of the amount which is repudiated by the opposite party. Subsequently the complainant preferred a review petition and the second claim is also repudiated by the opposite party. The complainant says that the 2nd opposite party willfully, with a malafide motive not to discharge the liability to pay the amount under the policy and applied unfair trade practice and repudiated the claim of the complainant. There is gross negligence and unfair trade practice on the part of the opposite parties. Hence filed this complaint.
3. Notices served to opposite parties and they filed version in short it is as follows:- Opposite party admitted the policy and stated that at the time of issuing the policy, as per the declaration of the complainant in the proposal form that the wife of the complainant had underwent a laparotomy due to ovarian cyst on 2012, so that the opposite party had issued the policy after excluding the complications and continuations of previous surgery for a period of 4 years from the scope of cover. That being so, the complainant was admitted on 12.09.2013 at Baby Memorial hospital, calicut for the treatment of pelvic adhesions, bilateral ovarian cysts, PID (pelvic inflammatory disease) and discharged on 23.09.2013. The history & physical examination column shows that in September 2012 she underwent ovarian cystectomy, was observed pelvic adhesions & abdominal pain was also persisted. The present procedure of total abdominal hysterectomy & bilateral salpingo oopherectomy done due to the adhesions of both ovaries adherent to the bowel & lateral pelvic wall, uterine body stuck to the lower anterior abdominal wall. In this case adhesions were released since there was dense adhesions between the anterior abdominal wall & peritoneum, small bowel adherent to the abdominal wall. It is submitted that the discharge summary of Vinayaka hospital, Suthan Bathery dated 18.09.2012 also shows that the wife of the complainant had undergone removal of para ovarian cysts & adhesions released. Based on the treatment records, the opposite party obtained an expert medical opinion which shows that the present removal of adhesions & surgical procedure are the complications & continuations of previous surgery done in 2012. Since the present treatment treatment is a continuation and complication of previous surgery, the 1st opposite party repudiated the complainant's claim vide letter dated 27.11.2013. After receiving the repudiation letter dated 27.11.2013, the complainant sent a letter dated 16.12.2013 to opposite party No.1 requesting for the claim to be re-opened and seeking relief for which a detailed reply was sent to the complainant. The complainant is a valid policy holder of opposite party since 17.07.2009 which has been renewed up to to 16.07.2011. Thereafter the complainant has taken policy of united India insurance from 17.07.2011 and continued there up to 16.07.2013. Further the complainant has taken insurance from the opposite party through portability from 23.07.2013 to 22.07.2014. Since the complainant has not fulfilled the conditions of portability as laid down by IRDA, the opposite party could not provide the continuity benefits & issued a fresh policy based on fresh proposal form with effect from 23.07.2013. At that time the opposite party has accepted the proposal after endorse & exclude the previous illnesses for a period of 4 years from the date of inception with the opposite party & it has been accepted by the complainant.
3. 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.
4. Point No.1:- Complainant filed affidavit and examined as PW1 and Ext.A1 to A5 and X1 series documents were marked and confronted document Ext.A6 also marked. Opposite party was examined as OPW1 and Ext.B1 to B6 documents were marked from the side of opposite parties. Complainant stated that he had paid Hospital bill of Rs.71,896/- in connection with the surgery of his wife and subsequently submitted claim form for reimbursement of the amount. But opposite parties repudiated the claim on the following reasons (1). Complications, continuations of previous surgery done (Laparotomy done due to ovarian cyst) & its related complications are specifically excluded under the policy schedule. (2). Two year exclusion:- You have taken the first year medical insurance policy from 23.07.2013 to 22.07.2014. You have undergone treatment for the above disease during first year of the policy. In this matter complainant has applied for portability of the policy with the opposite parties and paid Rs.6,374/- as premium up to the coverage of Rs.3 Lakhs and opposite party has issued policy in No. P/181315/O1/2014/OO1126 which is having the validity from 23.07.2013 to 22.07.2014. During the previous policy period the wife of the complainant had undergone a surgery for bilateral ovarian cyst in the year 2012. The complainant had disclosed the previous surgery to the opposite party while he is porting to the present policy. Even after the surgery cyst is again found and she had undergone treatment and another surgery was done to remove the cyst. But opposite party argued that at the time of issuing the policy, as per the declaration of the complainant in the proposal form that the wife of the complainant had underwent a laparotomy due to ovarian cyst on 2012, so that the opposite party had issued the policy after excluding the complications and continuations of previous surgery for a period of 4 years from the scope of cover. Based on the treatment records, the opposite party obtained an expert medical opinion which shows that the present removal of adhesions and surgical procedure are the complications and continuations of previous surgery done in 2012.
5. Opposite party further stated that as per IRDA norms if one wants to port his policy he should have apply before 45 day of renewal date. In this case date of renewal of the policy was 17.07.2013. But the complainant applied for portability on 13.07.2013 ie only 4 days before the date of renewal. Hence as per Ext.B7 he is not eligible for portability. In this matter as per Ext.B8 complainant applied for portability on 13.07.2013. Thereafter opposite party issued policy on receipt of premium amount. On perusal of Ext.A1 date of inception of the first policy is mentioned as 30 September 2008 and also previous surgery details are clearly mentioned in the policy. But opposite party contented that as per the declaration of the complainant in the proposal form that the wife of the complainant had underwent a laparotomy due to ovarian cyst on 2012, so that the opposite party had issued the policy after excluding the complications and continuations of previous surgery for a period of 4 years from the scope of cover. According to them based on the treatments records the opposite party obtained an expert medical opinion which shows that the present removal of adhesions and surgical procedure are the complications and continuations of previous surgery done in 2012. Since the present treatment is a continuation and complication of previous surgery, the 1st opposite party repudiated the complainant's claim vide letter dated 27.11.2013. Again they argued that complainant is a valid policy holder of opposite party since 17.07.2009 which has been renewed up to 16.07.2011. Thereafter the complainant has taken policy of United India Insurance from 17.07.2011 and continued there up to 16.07.2013. Further the complainant has taken insurance from the opposite party through portability from 23.07.2013 to 22.07.2014. Since complainant has not fulfilled the conditions of portability as laid down by IRDA, the opposite party could not provide the continuity benefits and issued a fresh policy based on fresh proposal form with effect from 23.07.2013. At that time the opposite party has accepted the proposal after endorse and exclude the previous illness for a period of 4 years from the date of inception with the opposite party and it has been accepted by the complainant. To substantiate this contention Ext.B7 and B8 documents were marked from the side of opposite party. As per Ext.B7 clause 3 and 3.1 clearly stated that “ A policy holder desirous of porting his policy to another insurance company shall apply to such insurance company at least 45 days before the premium renewal date of his/her existing policy. The Insurer may not be liable to offer portability if policy holder fails to approach the new insurer at least 45 days before the premium renewal date”. Again opposite party produced Application for portability (Ext.B8) dated 13.07.2013. As per Ext.A1 date of renewal is 17.03.2013 but on perusal of records we finds that complainant applied for the benefit of portability only 4 days back. Here raise a point for consideration that whether the complainant is entitled for portability. Conditions are being so opposite party's should have intimated the conditions to the complainant before they receiving the premium. Here nothing is there to shows that the opposite parties are duly intimated the conditions of the portability to the complainant. Hence we cannot accept the contention that complainant has not fulfilled the conditions of portability as laid down by IRDA. Opposite parties argued that they issued a fresh policy based on the fresh proposal form with effect from 23.07.2013 and the complainant accepted the proposal after endorse and exclude the previous illness for a period of 4 years from the date of inception with the opposite party but in the policy, date of 1st inception is mentioned as 30.09.2008. Complainant stated that he was opted portability on the belief that he will get its benefit at the time of acceptance of the premium, opposite party's not stated otherwise. If at all a specific condition is there opposite party's should have bound to intimate this to the complainant. At the time of claim they cannot raise such a contention that they were not accepted the portability and the policy issued is a new one. Hence the Forum finds that there is deficiency of service from the part of opposite parties. Point No.1 is found accordingly.
6. Point No.2:- Since the Point No.1 is found against the opposite party, they are directed to pay the claim amount with cost and compensation.
In the result, the complaint is partly allowed and the opposite parties are directed to pay Rs.71,896/- (Rupees Seventy One Thousand Eight Hundred and Ninety Six) as per Ext.A4 being the claim amount and Rs.2,000/- (Rupees Two Thousand) as compensation and Rs.2,000/- (Rupees Two Thousand) as cost of the proceedings to the complainant. 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 29th day of July 2015.
Date of Filing:25.07.2014.
PRESIDENT :Sd/-
MEMBER :Sd/- MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Johnson. P. J. Complainant.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Executive (Claims), Star Health Insurance Co Ltd,
Thiruvananthapuram.
Exhibits for the complainant:
A1. Insurance Police Schedule.
A2. Claim Repudiation Letter. Dt:27.11.2013.
A3. Claim Repudiation Letter. Dt:17.06.2014.
A4. Inpatient Bill(detail). Dt:23.09.2013.
A5. Copy of Letter. Dt:13.12.2013.
A6. Family Health Optima Insurance Plan.
X1(Series). Claim form, Discharge Summary, Inpatient Bill, other Bills and Lab Report.
Exhibits for the opposite parties:-
B1. Copy of Proposal Form.
B2. Copy of Insured Person details.
B3. Discharge Summary.
B4. Claim Form for Medical Insurance.
B5. Copy of Repudiation Letter.
B6. Copy of Letter. Dt:16.12.2013.
B7. Copy of Circular. Dt:09.09.2011.
B8. Proposal Form.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
