Order-14.
Date-18/05/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case, in short, is that OPs are insurance company Ltd. where the complainant had ported her previous existing medical insurance policy. OP3 is the agent broker of Insurance Company (OPs1 and 2) who had misguided the complainant and allured her to port her existing medical insurance to the existing medical insurance company. The complainant had her medical insurance with National Insurance in the year 2015 with her policy no. being 104200/48/14/8500009415. She had been paying her premiums to insurance company and continuing the same with the said insurance company. During June, 2015 the complainant had to undergo ovarian cystectomy at Divine Nursing Home, Kolkata on 12-06-2015 under Dr.(PROf.) Hiralal Konar and she was in hospital from 12-06-2015 and 18-06-2015. The cost of treatment of the surgery amounting to Rs.42,000/- was paid by National Insurance. Complainant, thereafter, ported his health insurance policy to the OP insurance company with policy No. being P/190000/01/2016/008868 for term period 01-12-2015 to 30-11-2016 and total sum insured being Rs.2 lakhs. A year later in August, 2016 the complainant required further hospitalization for a laparoscopic harnioplasty with placement of PCO mesh which was done under General Anaesthesia by Dr. Tapan Mukherjee on 21-08-2016 at UMA Medical Related Institute Pvt. Ltd. (Proforma OP). She was supposed to be discharged on 25-08-2016. The complainant deposited the requisite documents for getting the benefits of the said mediclaim policy. She underwent a total hospital bill amount of Rs.1,18,000/- on 25-08-2016. The complainant’s son-in-law contacted TPA desk of proforma OP hospital and head office of OP1 of Insurance company for document processing but to utter surprise the complainant received an intimation from the OPs that the claim had been rejected. Complainant, thereafter, had to arrange Rs.1,18,000/- for discharge and she had to stay at proforma OP hospital for another pay for arranging the money and she was discharged on 26-05-2016. The complainant has alleged unfair trade practice against the OP Insurance Companies and also deficiency in service. It is alleged that OPs Insurance company 1 and 2 have repudiated the claim of the complainant arbitrarily and illegally. Hence, this case.
OPs 1 and 2 have contested the case in filing written version contending, inter alia, that the case is not maintainable either in law or in fact. It is stated that the complainant took out a senior citizen red carpet Health Insurance Policy by porting policy from National Insurance valid from period 01-12-2015to 30-11-2016 subject to terms and condition limitation and exceptions thereof. During subsistence of the said policy complainant was admitted in UMA Medical, proforma OP on 20-08-2016 and submitted a preauthorization request for availing cashless facility for the treatment for ventral hernia. It is observed from internal verification of case history of the complainant of UMA Medical related institute that the complainant had midline swelling in the abdomen since 2/3 months following ovarian cystectomy one year back. It is also stated that the patient had a past history of ovarian cystectomy by midline. It is also stated that as per discharge summary of Divine Nursing Pvt. Ltd. dated 19-06-2015 that is prior to the inception of the Star Health Policy, the patient was diagnosed with huge pelvic abdomen mass ovarian tumor and laparotomy was done on 12-06-2015 which was not disclosed during the time of porting of the policy with the OPs i.e. from 01-12-2015 to 30-11-2016 which amounts to non-disclosure of materials facts. The pre-authorization of cashless was rejected and the same was informed to the treating hospital and also to the complainant vide letter dated 25-08-2016 issued by the contesting OPs. It is stated that the present claim for incisional is a complication of the earlier said surgery and had been done prior to the inception of the subject policy under portability with Star Health and was not disclosed insurance company. It is stated that the complainant did not disclose the material facts at the time of portability. It is stated that insurance is a contract based on utmost good faith and there is need on the part of the insured to be truthful at the time of taking the policy. It is also stated that the policy issued to the complainant is covered by Limits of Liability as per various clauses. It is also stated that at the time of portability the insured submitted a ‘no claim’ declaration stating that she or any member of her family did not make any claim under the insurance policies but national insurance company had duly paid Rs.42,000/- for the surgery of the complainant which took place at Divine Nursing Home in between 12-06-2015 to 18-06-2015. It is stated that the complainant, as such, violated the policy condition no.9 of the subject policy as such. It is stated that repudiation of the claim in as much as denial of pre-authorization for cashless treatment has been made within the four corners of the subject policy. This OP has prayed for dismissal of the case.
OPs 3 and 4 have not appeared in this case. The case has proceeded ex parte as against them.
Point for Decision
- Whether the OPs 1, 2 and 3 have rightly repudiated the claim of the complainant?
- Whether the OPs are deficient in rendering services to the complainant?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have perused the documents on record i.e. Xerox copy of PHSID of National Insurance in the name of the complainant, Xerox copy of discharge certificate of Divine Nursing Home, Xerox copy of final bill and discharge certificate of complainant dated 18-06-2015, Xerox copy of authorization of payment up to Rs.42,000/- of Paramount Health Services (TPA Pvt. Ltd.), Xerox copy of Senior Citizen Red Carpel Health Insurance Policy, Xerox copy of discharge certificate of Proforma OP Hospital, Xerox copies of money receipts, Xerox copy of rejection dated 25-08-2016 of Pre-Authorization for cashless treatment, Xerox copy of rejection of claim dated 27-08-2016 as filed from the side of the complainant.
We have also perused the documents which are filed from the side of the contesting OPs namely Xerox copy of subject Health Insurance Policy along with terms and conditions, Xerox copy of premium receipt, Xerox copy of proposal form duly filled in, Xerox copy of PAN Card of the complainant, Xerox copy of no claim declaration by the complainant, Xerox copy of insurance policy of National Insurance, Xerox copy of cystopathology report dated 18-06-2015 of the complainant, Xerox copy of patient case sheet, Xerox copy of USG of whole abdomen of the complainant, Xerox copy of rejection letter of claim dated 02-09-2016, Xerox copy of Pre-Authorization letter with estimate of proforma OP Hospital and other documents on record.
We find that the complainant took out Senior Citizen’s Red Carpet Health Insurance Policy by porting policy from National Insurance bearing Policy No.P/190000/01/2016/008868 valid for the period from 01-12-2015 to 30-11-2016 subject to terms and conditions, limitations and exceptions thereof. During the subsistence of the said policy the complainant was admitted in UMA Medical Related Institute, West Bengal on 20-08-2016 and submitted a per-authorization request for availing cashless facility for the treatment of ventral hernia. It is found from the case history of the patient of UMA Medical Related Institute that the complainant had midline swelling in abdomen since 2/3 months following ovarian cystectomy one year back. To put otherwise, the patient was previously admitted at hospital for ovarian cystectomy by midline. From the discharge summary of Divine Nursing Home dated 19-06-2015, it also appears that the patient was diagnosed with huge pelvic abdomen mass ovarian tumor and laparotomy was done on 15-06-2015. It is stated that such fact was not disclosed during the porting of the policy of the OPs and it amounts to non-disclosure of material fact as per condition no.9 of the said policy. We find that preauthorization of cashless was rejected in consideration of pre-existence of the said disease. It is also stated that the complainant has not disclosed about pre-existence of such disease at the time of portability. Hence, the subject claim was repudiated for non-disclosure of pre-existing disease.
We find that the new SCRC Health Insurance policy of the complainant is basically a continuation of the benefits of the previous health insurance policy of National Insurance. The new policy had categorically listed the continuity benefits which are applicable to be continued with new insurance policy as provided therein.
Name | L.D. No. | 30 Days waiting period | 1st Year Exclusions | First Two Year Exclusion | Pre-Existing Disease |
Smt. Rita Acharjee | 4713456-I | Waived | Waived | Waived | Covered |
We find that pre-existing disease is covered under the policy. So, we think that OP insurance company cannot agitate on that point. We think that since the policy covers pre-existing disease, the argument of the OP Insurance Company that complainant suppressed pre-existing disease is not tenable. The question of suppression of pre-existing disease looses its significance in view of terms and conditions, limitations and exceptions of the subject policy. As per condition No.5 of the subject policy, as we find, 50 percent of cost will be borne by the insured himself in respect of the claims with regard to expenses of pre-existing disease as defined and 30 percent of the cost will be borne in respect of the claim which is not related to the pre-existing disease. We also find that Senior Citizen Red Carpet Policy issued to the complainant is covered by Maximum Limit of Liability’sClause and co-pay conditions. We find that the policy issued to the complainant under whom the dispute has been raised is covered by Limits of Liabilities as per various clauses. So, we think that the OP Company is liable to pay the claim as per 50 percent Co-pay of the contract of insurance issued to the complainant. We think that OPs Insurance company have not been justified to repudiate the claim of the complainant on the ground of pre-existing disease. We find from the medical papers that complainant has a history of ovarian cystectomy by midline and as per histopathology report dated 08-06-2015 the patient was diagnosed with endomentrial polyp, chronic cervicities, mucinous cystadenoma of ovary but as per the terms and condition of the subject policy, pre-existing disease is covered. we find that the complainant had incurred a total hospital bill of the amount of Rs.1,18,000/-. The complainant is entitled such expenditure as per condition no.5 of the subject policy.
Consequently, the case merits success.
Hence,
Ordered
That the complaint be and the same is allowed on contest against the OPs1, 2 and dismissed ex parte as against the OPs3 and 4.
OPs 1,2 and 3 are jointly and severally directed to pay an amount of Rs.59,000/- being 50 percent of the total expenditure of Rs.1,18,000/- apart from litigation cost of Rs.10,000/- to the complainant within one month from the date of this order.
OPs are also jointly and severally directed to pay an amount of Rs.10,000/- for causing harassment, mental pain and agony to the complainant within the said stipulated period.
We make no order as against OPs 3 and 4.
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.
