Order-19.
Date-22/11/2016.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the Complainant in short is she purchased a Medi-Classic Insurance Policy No. P/191116/01/2014/002885 from OP Company for a period of 8th November, 2011 to 7th November,2012. The said premium has been renewed year to year without any interruption or default and the Complainant also paid annual premium of Rs.5, 096/- for the year 2013-2014. The Complainant said that some time in Janbuary,2012 she began suffering from “Amenorrhea” (a gynecological problem i.e. missing of regular period). She visitedDr. Priya Royand as per advice, underwent USG. From the tests it transpires that the Complainant had polycysticovary and she underwent operation on 01.12.2012. But her condition did not improve. In May,2013 she went to Dr. S.K.Bhattacharya for severe Pedal edema, for weight gain, palpitation hypertension, high sugar etc. She also had USG again on 14.5.2013 and SOL was detected. Thereafter, she underwent continuous hormonal treatment. She also underwent CT scan of the whole abdomen on 27.7.2013. It was found that was suffering from a disease, whose medical terminology is “Pheochromocytoma”. She was also advised to undergo operation. She went to Christian Medical College, Vellore for treatment and operation of the Mass. She was admitted in CMC, Vellore on 28.11.2013 and a claim was sent to the OP Company and the OP authorized cashless treatment of the Complainant for Rs.30,000/- for surgical treatment. The OP Company subsequently enhancedtreatment amount from Rs.30,000/- to Rs.68,000/- to the complainant and she availed of the cashless benefit scheme. From a series of tests for over 14 days by Drs. of CMC, Vellore, doctors to Velloresuggested that it was not a case of ‘Pheochromocytoma’. The Doctors finally suggested that it was adrenocortical Carcinoma. In December, 2013 the Complainant firstly came to know that she was suffering from the said disease. The Complainant was advised to undergo an operation as the said disease is Cancerous in nature and she underwent an operation on 13.12.2013.The Complainant thereafter advanced claim to OP further for cashless treatment.The request of the Complainant and the preauthorization of the cashless treatment on 12.12.2013 for surgical management was denied by the OP vide its letter dated13.12.2013 on the ground that the patient is symptomatic since 2013. The Complainant further persuaded the second claim for cashless treatment, but the OP vide its letter dated 16.12.2013 again denied the claim stating that the said symptomsindicate the disease prior to policy. On 24.12.2013 OP, however, sent a letter to the Complainant advising her to send original documents to process the claim for reimbursement for the surgical management of the adrenal mass. The Complainant duly sent the claim form along with all necessary documents. OP Company, thereafter vide letter dated 05.03.2014 repudiated her claim primarily on the ground of misrepresentation and non disclosure of the material facts alleging that at the time of inception of the first policy, the Complainant had not disclosed her true medical history and it was violation of condition no. ‘6’ of the Policy. The repudiation letter was also accompanied by a letter dated 12.03.2014 contemplating cancellation of the policy. It is alleged by the Complainant that such repudiation is not genuine and gross violation of the rules of IRDA guidelines. It is also alleged that she was illegally deprived of her insurance coverage or benefit. Hence, this case.
The OP has contested the case in filing w.v contending inter alia that the case is maintainable in fact and in law. It is also stated that the Complainant has not approached this Forum with clean hands and has suppressed material facts in the present complaint. It is stated that the Complainant was hospitalized at CMC, Vellore from 12.12.2013 to 20.12.2013. The OP authorized cashless treatment of the Complainant for Rs.30,000/-.The answering OP had enhanced the approved amount to Rs.68,000/- vide same claim intimation no. CLI/2014/191116/0170330 dated 12.12.2013 for the same hospitalization. However, subsequently, the authorization or approval was withdrawn by the answering respondent in the said claim intimation. It is also stated that the medical history of the Complainant recordedby the treating Doctors at CMC, Vellore at the time of alleged treatment clearly shows that the Complainant / Insured-patient had “amenorrhea and pedal edema 2 (two) years ago along withhirsutism and hypertension” which implies the disease was subsisting and existing during the policy inception and the Complainant and was well aware of the same. It is alleged that the Complainant deliberately choose not to disclose her medical history and health hazard and suppressed the material facts from the answering OP. This OP has prayed for dismissal of the case.
Points for decision
- Whether OP has been deficient in rendering service?
- Whether OP has repudiated the claim of the Complainant rightfully?
- Whether the Complainant is entitled to get the relief as prayed for?
Decision with reasons
All the points as above are taken up together for discussion for the sake of brevity, convenience of discussion and as the points are inter related having bearing upon one another.
We have travelled over the documents on record namely photocopy of Medi-Classic Insurance Policy, photocopy of payment receipts, photocopy of ECG report, photocopy of prescriptions, photocopy of correspondences on different dates in between the parties, photocopy of Claim form, photocopy of discharge summary of CMC, Vellore Hospital, photocopy of proposal form and photocopy of other documents on record.
It is worthy to point out at the very outset that the Complainant filed Examination in Chief and, thereafter, did not turn up to proceed with the case. OP filed questionnaire as against the Evidence on Affidavit filed by the Complainant. The Complainant did not reply to the questionnaire of the OP. Thereafter, OP also filed Evidence on affidavit. Complainant did not turn up to file any questionnaire to the OP as against the evidences on affidavit.
It appears that the Complainant took a Medi-Classic Insurance Policy for the first time with coverage from 08.11.2011 to 07.11.2012 and which has been renewed thereafter in the year 2013-2014. The Complainant was hospitalized at CMC, Vellore from 12.12.2013 to 20.12.2013, against which Insurance request was sent and granted by the answering OP vide claim intimation no.CLI/2014/191116/0170330 dated 29.11.2013 and again answering OP had enhanced an amount of Rs.68,000/- vide same claim intimation No.CLI/2014/191116/0170330 dated 12.12.2013 for the same hospitalization. However, such authorization or approval was subsequently withdrawn by the Respondent for the said 2 intimation nos., as stated a little earlier.The ground for repudiation as we find is suppression of material facts. It is stated that the OP was suffering from “amenorrahea” and pedal edema along with “hirsutism and hypertension” since two years prior to her hospitalization.
We have perused the discharge summery of CMC, Vellore.From such discharge summary it appears that the Complainant had amenorrahea and pedal edema two years ago, for which she stared hormonal therapy elsewhere, which was ineffective. The Complainant did not face the cross-examination from the side of the OP on this point. The evidence of OP on this score that she had preexistingdisease at the time of obtaining policy is not also controverted from the side of the Complainant. Evidence of the Complainant has been challenged by the OP and Complainant did not turn up to answer the questionnaire. The evidence of affidavit filed by the OP on this score also remains unchallenged and uncontroverted. It is stated from the side of the OP that the Complainant is symptomatic since 2011.
Be that as it may, duration of the illness is not very clear before us or whether it developed before obtaining the subject Policy or not. In fact, Complainant has not come up before the Forum to challenge the version of the OP. Complainant did not face the questionnaire on this point. The case of the OPthat the disease was subsisting and existing before the policy inception stands in absence of any controverting evidences a recorded.
It appears from the policy document that a patient is not entitled to get the policy benefit unless 48 consecutive months of continuation coverage have elapsed since inception of the first policy with the insurer (clause 3 of the policy document).In absence of any contrary and controverting material on record and as the Complainant did not face cross examination and also in view of the evidence of the OP being unchallenged, we think that the claim of the Complainant does not sustain.
In result, the case, fails.
Hence,
Ordered
That the instant case be and the same is dismissed on contest but on merit against the OP.
We make no order as to cost.
