For the Complainant                       -  Soma Roy, Ld. Advocate

For the OP                                         -  Nalines Kr. De, Ld. Advocate

FINAL ORDER/JUDGEMENT

SMT. SAHANA AHMED BASU, MEMBER. 

Facts of the instant consumer complaint, in brief, are that complainant opted a mediclaim policy, namely, Family Health Optima Insurance Plan being No. P/191119/01/2017/013361 from the O.Ps. for himself along with his family members for the period from 27/03/2018 and the sum assured was Rs.5,00,000/- with Bonus of Rs.75,000/- and recharge benefit  Rs.1,50,000/- and the policy is still in continuation. On 25/04/2017, being advised by the attending doctor, complainant was admitted to AMRI Hospital, Dhakuria with acute pain on her right knee. Before admission, while the hospital authority proceeded for cashless preauthorization from the O.Ps., that was rejected on the ground that OSTEOARTHRITIS RT KNEE falls with the second year waiting period and as per the policy conditions the claim was not admissible and that was rejected. Therefore, getting release from the hospital, complainant submitted her claim for Rs.1,92,530.64 along with all the relevant papers. Complainant submitted that as per the policy conditions waiting period does not fall for knee replacement. Thus, the complainant has filed this complaint.

O.P. has contested the petition of complaint by filing W.V. strongly disputing and denying the every allegation and averment of the complainant. O.P. has stated that the complaint is premature and no locus standi, there is suppression material facts and misleading. O.P. also stated that At the time of incepting the policy, there is no whisper about any previous and/or existing illness. As the disease of the complainant was diagnosed as OSTEOARTHRITISRT KNEE, which falls with the 2^nd year waiting period and according to the policy condition, they could not approve the cashless request. Complainant never file any claim with bill or cash memo for reimbursement and they are in dark about the expenses incurred by the complainant for her treatment. Thus, there is neither any deficiency in service nor unfair trade practice on their part.

In the backdrop of above facts following points are arisen for determination.

1. Whether the claim of the complainant was wrongfully repudiated by the O.Ps.
2. Whether the O.Ps. practiced  unfair trade.
3. Whether the claim of the complainant is tenable in law.  

Decision with Reasons

Points No. 1 to3.

All the points are taken together for the sake of convenience and brevity in discussion.

Both parties have tendered  evidence and replied to the questionnaires set forth by their adversaries. Both parties have filed BNAs. We have gone thoroughly to the documents on record and gave our careful consideration.

It is admitted fact that the complainant obtained a mediclaim policy, namely, Health Optima Insurance Plan with her family members being policy No.P/191119/01/2017/013361 from the O.Ps. for the period from 27/03/2017 to 26/03/2018 for sum assured of Rs.5,00,000/- with bonus of Rs.75,000/- and recharge benefit of Rs.1,50,000/-.

On perusal of the documents on record furnished by both the parties, we find that the policy was purchased on 27/03/2015 and it is continuing till 26/03/2016. The complainant was admitted to AMRI Hospital, Dhakuria on 20/04/2017 with acute pain of left knee and as per advice of her attending physician Dr. Kanchan Bhattacharya. Photocopy of the prescription is annexed with the petition of complaint. Before admission, complainant proceeded for Cashless facilities of mediclaim  with the O.Ps. through the hospital authority but that was rejected by the O.Ps. vide letter dated 21/04/2017 stating that “The diagnosis and management of the disease namely OSTEOARTHRITIS RT KNEE falls with the 2^nd year  waiting period. As per the policy condition we regret the claim is not admissible and cashless request is rejected. Therefore, we express our inability to consider  this claim and consequently the request for preauthorization cannot be approved.” Thereafter, the complainant filed reimbursement claim to the O.Ps. for an amount of Rs.1,92,530.64 only in respect of the medical expenses incurred by her during hospitalization. The complainant also alleged that as per the policy condition, ‘waiting period’ is not related to the subject policy in regard to disease for knee replacement as suffered by the complainant. But the O.Ps. have never showed their will to settle  the claim and delaying the intentionally.

Ld. Advocate for the O.Ps. has defended such allegation and submitted that in exclusion the terms and conditions of the policy Clause-3(d) clearly clarified that during the first two years of continuous operation of insurance cover any expenses on :

“Conservative, operative treatment and all types of intervention for diseases related to tendon, ligament, fascia, bones and joint (other than caused by accident)”. More so, it was further clearly mentioned in the terms and conditions that “This waiting period shall not however apply in the case of the Insured person/s  having been covered under any individual health insurance scheme with any of the Indian Insurer for a continuous period of preceding 24 months without any break.”

            Therefore, the claim of the complainant is not admissible as per policy conditions as the diagnosis falls with the 2^nd year waiting period and as such cashless request was rejected. We find there is logic in the submission of the O.Ps. and there is no deficiency in service on the part of the O.Ps.

            Another allegation is agitated by the complainant that the O.Ps. remained unturned in respect of the reimbursement claim of the complainant. O.Ps. again strongly defended such allegation submitting that complainant did not lodge any claim with the O.Ps. by sending any piece of paper in regard to reimbursement of her claim. As such, O.Ps. are not aware of the exact amount incurred by the insured during hospitalization. On depth scrutiny of the documents on record, it reveals that complainant lodged reimbursement claim with the O.Ps. along with discharge certificate and a certificate from Dr. Kanchan Bhattacharya endorse with “To whom it may concern” bearing the fact that the complainant was diagnosed with pain in both knee joints for four months instead of few years as issued by the AMRI Hospital in their discharge note. No bill is attached with the claim on behalf of the complainant. Therefore, it cannot be said that O.Ps. adopted unfair trade practice by not turning up themselves to the matter of alleged reimbursement.

            It is true that the complainant underwent a critical surgery for which she had to incur huge expenses but considering the terms and conditions of the mediclaim policy, which is regulated by the IRDA too, our hands are tight to allow any relief / reliefs  to the complainant. Parties are bound to obey the terms and conditions of the policy. Thus, the complainant is not entitled to get any relief as prayed for. Therefore, all the points are answered in the negative.

In the result, the case merit fails.

Hence,

Ordered

That the complaint case be and the same is dismissed on contest.

Parties do beat their own cost.