Order-18.
Date-03/03/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short is that he took a Family Health Optima Insurance Policy being Policy No.P/191112/01/2014/001930 commencing from 19.07.2013. The policy was renewed from time to time and was valid up to mid night of 19.07.2016 against the payment of consideration as premium of the said policy for a sum of Rs.12,152/- per year, duly revised from time to time covering hospitalization benefit for two adults of Rs. 3 lakhs, Basic Floating Sum Insured for himself and for his wife.
The Complainant had a complaint of heart failure and the diagnosis disclosed Double Vessel Disease for which he contacted the Dr. Uday Narayan Sarkar on 06.11.2014, who after formal check up advised him to get admitted in Hospital. The Complainant as per Dr. Advice was admitted on 06.11.2014 in Nightingale Hospital, Kolkata-700 071 for his treatment. OP No. 2 was informed within 24 hours for his admission in the Hospital by the Hospital authority to process for cashless hospitalization. OP No. 2 refused to process for cashless facility for the treatment of the Complainant. However OP No. 2 advised that the insured person may submit the hospital paper for reimbursement and the claim will be settled after investigation. The Complainant was discharged from the Hospital on 15.11.2014. The Hospital also charged a sum of Rs.1, 44,064/- and Rs.54,000/- from the Complainant and the Complainant paid the same. The Complainant had to pay for other medicines apart from aforesaid expenses. The Complainant on 18.09.2014 lodged the claim submitting a Mediclaim Form giving details of the treatment and expenses incurred by the Complainant for such treatment. But the Insurance Company made no reply. The Complainant also wrote several letters and reminders to OP No. 1, but to no good. It is alleged that the OPs did not consider the claim of the Complainant and failed to render proper service to the Complainant. Hence this case.
OP Nos. 1 and 2 have contested the case by filing w.v. contending inter alia that the instant case is not maintainable either in fact or in law and is devoid of merit. It is alleged that the Answering OP raised query on pre authorization dated 14.11.2014 from the Complainant through Hospital. The Hospital, Nightingale subsequently, provided the desired previous treatment records of the Complainant. It is also alleged that the records of the treating Doctor showed that patient is ‘Dyslipidemic’ and have past history of recurrent episodes of chest discomfort palpitation and Cag and Echo reveals significant Double Vessel Disease, which is a pre-existing disease. As a result, the OP was legally constrained to repudiate the alleged Cashless claim of the Complainant.It is alleged that the Complainant did not disclose about the disease and as such the Insurance Company is not liable to make any payment in respect of any claim. It is alleged that the OPs are not deficient in service. It is also stated that the Answering OPs sent three reminders including a verbal reminder to the Complainant dated 27.05.2011, 09.06.2011 and 03.11.2015 in context to the reimbursement preferred by the complainant requesting the Complainant to submit necessary documents relating to first hospitalization papers as the Complainant had past history of recurrent spells of palpitation, but the Complainant did not pay any heed to submit the necessary papers. These OPs have prayed for dismissal of the case.
OP No. 3 also contested the case in filing W.V. contending inter alia that the instant case is not maintainable against this OP. It is also stated that that the Complainant has not made the treating Doctor a party in this case. It is also stated that this OP has no deficiency in service or negligence and no relief also claimed against this OP. It is also stated that Hospital authority has not received any amount of Insurance Policy and has given best service to the Complainant as per Doctor’s advice and medical protocol. This OP has prayed for dismissal of the case against it.
Point for Decision
1) Whether the OPs have been deficient in rendering service to the complainant?
2) Whether the OPs have acted illegally or arbitrarily in not entertaining the claim of
the Complainant?
3) Whether the Complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have perused the documents on record i.e. photocopy of Family Health Optima Insurance Plan, photocopy of medical papers of Nightingale Hospital, photocopy of prescriptions and discharge summary and other documents on record.
It appears that the Complainant purchased a Family Health Optima Insurance Policy being Policy for two adults for sum insured of Rs. 3 lakhs, floating basis bearing Policy No.P/191112/01/2014/001930commencing from 19.07.2013 and the said policy was renewed every year and the last policy being No. P/191112/01/2015/001769 was renewed for the period from 20.07.2015 to 19.07.2016. We find that the Complainant had a Heart failure on 06.11.2014 and diagnosed disclosed “Double Vessel Disease“. The Complainant was admitted at Nightingale Hospital being OP No. 3 on 06.11.2014 and was discharged from Hospital on 15.11.2014 and final bill amount raised is of Rs.1,44,064/-. The Complainant lodged a mediclaim before the OP, but no response was given by the Insurance Company regarding reimbursement of medical expenses. However, we find that OP No. 1 and 2 raised query on “pre authorization” against the cashless request sent on behalf of the Complainant dated 14.11.2014 finding that patient is symptomatic since 1.5 years for Cardiac ailment. Subsequently, said Nightingale, Kolkata, provided previous treatment records of the Complainant to OP No. 1 and 2. OP No. 2 came to know that patient is ‘Dyslipidemic’ and had past history of recurrent episodes of chest discomfort, palpitation and Cag and Echo reveals significant Double Vessel Disease.
The answering OP No. 1 and 2 as such denied the claim of Complainant on the ground that it was a ‘pre-existing disease’. It is also stated by the OP No. 1 and 2 that the Complainant has preferred this claim in the 2nd year of his Policy and as such he is not entitled either to cashless claim or hospital reimbursement citing ‘Pre-existing disease’.
We have perused the exclusions clause of the Insurance Policy.Nowhere it is appearing from such clause that “Double Vessel Disease” is excluded from the Insurance coverage. It is not explained specifically, what are the ‘pre-existing disease’ or what are the criteria to ascertain that a particular disease is ‘pre-existing’. Be that as it may, Double Vessel Disease is not excluded anywhere in the exclusion clause. Moreover, we think that it is the duty of the Insurance Company to examine a person medically before issuance or grant of Insurance Policy. It is curious that the Insurance Company issued the mediclaim in favour of the Complainant and his wife without examining them medically or for ascertaining whether they have any disease which may be termed as ‘pre-existing’. So, we think repudiation merely on the pretext of ‘pre-existing disease’ does not hold good and as such, an argument on such score is not also sustainable. We think it is the indispensableduty on the part of the Insurance Company to examine a person to be insured for mediclaim before sanction of the mediclaim policy. OPs have not provided any document to show that the Complainant suffered from ‘Double Vessel Disease’ and unfit for mediclaimhaving ‘pre-existing disease’. The alleged repudiation of the insurance claim of the Complaint citing ‘pre-existing disease’ is not sustainable. We think that the OPs 1 and 2 have illegally repudiated the claim of the Complainant for reimbursement. We also find that no previous Cardiac failure reference were provided either by the Hospital or by any authority to prove or come to a definite conclusion that the Complainant has past history of recurrent episodes of chest palpitation etc.
We think that OPs 1 and 2 have been deficient in rendering service to the Complainant. They have also exhibited a gesture of gross negligence and/or arbitrarily and illegally repudiated the mediclaim insurance of the Complainant. We find that the Complainant incurred expenses of Rs.1,44,064/- as per the final bill. No bill however is submitted in respect of Rs.54,000/- by the Complainant alleged to have been paid by the Complainant. We think that OPs 1 and 2 have to make reimbursement of the medical expenses of the Complainant.
In result, the case succeeds.
Hence
Ordered
That the instant case be and the same is allowed on contest against the OPs1 and 2 and dismissed against the OP No. 3.
OP No. 1 and 2 are directed to pay an amount of Rs.1,44,064/- to the Complainant apart from litigation cost of Rs.10,000/- to be paid within one month from the date of this order.
OP No. 1 and 2 are also directed to pay a sum of Rs.10,000/- as compensation for causing harassment, mental agony and pain to the Complainant within the said stipulated period.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P. Act.
