Order No.  10  dt.  13/06/2018

        The case of the complainant in brief is that the complainant purchased one mediclaim insurance policy named Basis Floater in the year 2005 and since then he is continuing the policy without any breakup by paying premium as required by o.p. The policy was renewed in Jan. 2017 and the policy was valid from 27.1.17 to 26.1.18. The complainant all on a sudden became ill on 21.3.17 and he was admitted to B.M. Birla Heart Research Centre and he was discharged on 24.3.17. The authorities of o.p. contacted at the said hospital and denied the claim in writing on the ground that the complainant’s case falls under exclusion 1 of the terms of the agreement stating that the complainant has pre existing disease. The complainant was compelled to pay an amount of Rs.1,85,000/- and since the complainant was not provided with the cashless facility for which the complainant faced mental agony and harassment and as such, the complainant filed this case praying for direction upon the o.p . for payment of the amount of Rs.1,85,000/- as well as compensation and litigation cost.

            The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant did not file any claim from along with original receipts of expenses with o.p. as claim contained in the claim procedure of the subject insurance policy and therefore, for non compliance of claim procedure compliance, the complaint is not at all maintainable. It was further stated that the policy was issued by Patna branch of o.p. covering the risk of the complainant and his wife for a sum insured value of Rs.3 lakhs subject to terms, conditions, limitations etc. During pre insurance medical examination report findings the followings are added as PED (pre existing disease) in the policy with respect to Mr. Satish Kr. Verma. During the subsistence of the said policy o.p. received a cashless request, but the same was not entertained since the complainant had the pre existing disease and the complainant after getting relief from his disease he could have filed the claim to the insurance company. The o.p. also stated that as per exclusion clause no.1 of the policy the company is not liable to make any payment in respect of expenses for treatment of the pre existing disease / condition, until 48 months of continuous coverage has elapsed, since inception of the policy on 27.1.15 and as per exclusion clause no.1 of the policy the claim against pre existing disease is not payable until expiry of 48 months from the date of inception of the 1^st policy. The o.p. also stated that the complainant did not make any claim to o.p. with original documents of the medical expenses and therefore the claim made by the complainant that there was deficiency in service or unfair trade practice on the part of o.p. cannot be accepted. On the basis of the said fact o.p. prayed for dismissal of the case.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant had the policy at the relevant point of time?
2. Whether during the subsistence of the said policy the complainant became ill and he was admitted to the hospital?
3. Whether the complainant suppressed the pre existing disease and obtained the policy?
4. Whether there was any deficiency in service on the part of o.ps.?
5. Whether the complainant will be entitled to get the relief as prayed for?

Decision with reasons:

            All the points are taken up together for the sake of brevity and avoidance of repetition of facts.

            Ld. lawyer for the complainant argued that the complainant purchased one mediclaim insurance policy named Basis Floater in the year 2005 and since then he is continuing the policy without any breakup by paying premium as required by o.p. The policy was renewed in Jan. 2017 and the policy was valid from 27.1.17 to 26.1.18. The complainant all on a sudden became ill on 21.3.17 and he was admitted to B.M. Birla Heart Research Centre and he was discharged on 24.3.17. The authorities of o.p. contacted at the said hospital and denied the claim in writing on the ground that the complainant’s case falls under exclusion 1 of the terms of the agreement stating that the complainant has pre existing disease. The complainant was compelled to pay an amount of Rs.1,85,000/- and since the complainant was not provided with the cashless facility for which the complainant faced mental agony and harassment and as such, the complainant filed this case praying for direction upon the o.p . for payment of the amount of Rs.1,85,000/- as well as compensation and litigation cost.

            Ld. lawyer for the o.p. argued that the complainant did not file any claim from along with original receipts of expenses with o.p. as claim contained in the claim procedure of the subject insurance policy and therefore, for non compliance of claim procedure compliance, the complaint is not at all maintainable. It was further stated that the policy was issued by Patna branch of o.p. covering the risk of the complainant and his wife for a sum insured value of Rs.3 lakhs subject to terms, conditions, limitations etc. During pre insurance medical examination report findings the followings are added as PED (pre existing disease) in the policy with respect to Mr. Satish Kr. Verma. During the subsistence of the said policy o.p. received a cashless request, but the same was not entertained since the complainant had the pre existing disease and the complainant after getting relief from his disease he could have filed the claim to the insurance company. The o.p. also stated that as per exclusion clause no.1 of the policy the company is not liable to make any payment in respect of expenses for treatment of the pre existing disease / condition, until 48 months of continuous coverage has elapsed, since inception of the policy on 27.1.15 and as per exclusion clause no.1 of the policy the claim against pre existing disease is not payable until expiry of 48 months from the date of inception of the 1^st policy. The o.p. also stated that the complainant did not make any claim to o.p. with original documents of the medical expenses and therefore the claim made by the complainant that there was deficiency in service or unfair trade practice on the part of o.p. cannot be accepted. On the basis of the said fact o.p. prayed for dismissal of the case.

            Considering the submissions of the respective parties it is an admitted fact that the complainant obtained the policy from o.p. and during the subsistence of the policy he became ill and he was admitted to the hospital for his treatment. On perusal of the policy issued by o.p. it appears that in the policy itself it was mentioned against the name of the policy holder i.e. the complainant PED i.e. pre existing disease diabetes, hypertension, cardiovascular disease and their complications. In the policy document it was stated that if the complainant would have any grievance against the incorporation of such PED in the policy document the complainant could have lodged any discrepancy in the policy document could have made a complaint to insurance company within 15 days from the date of receipt of the policy. But it is unfortunate that the complainant did not raise any objection regarding incorporation of PED in the policy document itself. After the lapse of several years it appears that the complainant became ill and he was admitted to the hospital and it is curious enough that the complainant at the time of application for obtaining the policy did not disclose that he ever suffered or suffering from any of the following diseases viz. diabetes mellitus whereby it was stated that he never suffered from any such disease. After detection of the pre existing disease and considering the medical report of the insured the pre existing disease was mentioned in the policy document and as per exclusion clause until 48 months of continuous coverage has elapsed since inception of the policy and as per the said exclusion clause no.1 of the policy insurance company rightly rejected the pre authorization of the cashless benefit to the complainant. Ld. lawyer for the complainant during the argument stated that after getting relief the complainant submitted his bill to the Govt. of West Bengal and the Govt. paid the bill amount and therefore, the complainant only wanted to have the compensation and litigation expenses in respect of the case filed by him against the o.p. Ld. lawyer for o.p. by filing several documents clearly established that the complainant himself suppressed the material fact that he was not suffering from any illness and in the policy document itself there was mentioning of pre existing disease which has not been denied by the complainant after obtaining the policy from o.p. In view of such facts and circumstances of the case since there was pre existing disease and as per exclusion clause no.1 of the policy the pre existing disease has been defined whereby it has been stated that until 48 consecutive months of continuous coverage has elapsed since inception of the policy with any Indian insurer and on the basis of the said exclusion clause the claim of the complainant for pre authorization of cashless benefit was rightly rejected by insurance company and accordingly we hold that the case filed by the complainant has got no merit and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.

            Hence, ordered,

            That the CC No.RBT/CC/306/2017 is dismissed on contest without cost against the o.p.