IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 27th day of April, 2023
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 111/2022 (Filed on 23-05-2022)
Petitioner : Emil C. Varghese,
Co. Ltd. S/o. T.M. Varghese,
Thakadiyelparambil House,
Panachikkad, Nattakom,
Kottayam – 686 533
(Adv. Thomas Sebastian)
Vs.
Opposite party : Star Health and Allied Insurance Rep. by the Branch Manager,
Star Health and Allied Insurance Co. Ltd
II Floor, Puthenpurackal Compled,
MC Road, Kodimatha, Kottayam
(Adv. Avaneesh V.N.)
O R D E R
Sri. Manulal V.S. President
Case of the complainant is as follows.
The complainant is a medi claim policy holder of the opposite party vide policy numberr P1181113/01/2021/009584 valid from 23-11-2020 to 22-11-2021. The complainant having a continuity of medi claim policy from 25-11-2014 to 24-11-2020 by name Arogya Maithri of New India Assurance company. The complainant switched to opposite party’s Mediclassic policy (Individual) from 23-11-2020 after paying a premium of Rs.3869/-. The complainant was admitted to SH Medical Centre hospital on 3-8-2021 for the treatment of Decompensated Anaemia Secondary to GI Blood loss and was discharged on 6-8-2021 advising surgery for Haemorrhoid. On 7-8-2021 he was admitted to KIMS hospital Thiruvananthapuram and stapler Haemorrhoidectomy done under S A on 8-8-2021 and was discharged on 10-8-2021 and was referred to Spring Grade Medical Specialists and Family Clinic, Thiruvananthapuram and he was treated their till 11-8-2021complainat had spent Rs.31,823 at SH Medical Centre and Rs.95,311.05 at KIMs Health, Thiruvanthapuram and an amount of Rs.12,028/- was spent at Spring Garden Hospital towards treatment expense. Thus complainant had spent total amount of Rs.1,39,162/- for his treatment. Though the complainant submitted a claim form to the opposite party along with the bills and treatment details for reimbursement of the medical bills, the opposite party repudiated the claim stating that the company is not liable to make any payment in respect of expenses related to the treatment of a pre-existing disease and its direct complications until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer from ie.23-11-2020. According to the complainant his policy is a switch over policy and it has got a continuity right from 25-11-2014. The rejection of the complainant’s claim is violation of the policy conditions and amounts to deficiency in service on the part of the opposite parties. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to reimburse Rs.1,39,162/- along with a compensation of Rs.50,000/- and cost of this litigation.
Upon notice opposite party appeared before the commission and filed version as follows:
The opposite party had issued Medi classic Individual insurance policy vide policy number P1181113/01/2021/009584 valid from 23-11-2020 to 22-11-2021 for a sum insured of Rs.2,00,000. At the time of availing the policy the complainant was supplied with the terms and conditions of the policy and the same was explained to the complainant.
The policy is issued in good faith on the basis of the declaration and details entered in the proposal form. The proposer has intentionally suppressed in the proposal form despite there is specific health history column that “do you have any health problems”-The complainant had answered ‘No’ to the specific question.
The complainant had registered two claims during the first year of the policy. In the first claim, the complainant was admitted at S H Medical Centre Kottayam on 3-8-2021 for the treatment of Decompensated Anaemia Secondary to GI blood Loss and after the treatment he was discharged on 6-8-2021. Complainant had submitted the form, discharge summary, lab reports and bills for Rs.31,823/-. Discharge summary issued by the SH hospital reveals that the complainant has taken endoscopy and colonoscopy done which revealed Antral gastritis and Haemorrhoids. CECT abdomen suggested for small bowel evaluation, surgical option for haemorrhoids was suggested.
In the second claim the complainant was admitted at Kims hospital, Thiruvanthapuram for the treatment of lower GI bleed and underwent Stapler Haemorrhoidectomy and after the treatment he was discharged on 10-8-2021.Discharge summary issued by KIMS hospital reveals that the complainant had complaints of occasional bleed per rectum (PR) since 4 to 5 years. Thus it is evident that the complainant had history of present ailment before the inception of the policy and the same was not disclosed in the proposal form and it is non-disclosure of pre-existing disease. So, the complainant has not disclosed any previous insurance policy. So even if there is any policy it was not ported to the present policy.
The ailment for which the patient is admitted and treated is a complication of the pre –existing disease. As per Exclusion no. IV(1)(A) of policy any pre-existing disease will be covered under the policy only after completion of 48 months continuous coverage after the date of inception of the first policy with the opposite party. Moreover as per exclusion clause no. IV(2)(A) and (F)(11) of the policy expenses related to the treatment for Fistula, Fissure in Ano, Haemorrhoids, pilonidal sinus and fistula, Rectal Prolapse, Stress Incontinence are excluded until the expiry of 24 months of continuous coverage after the date of inception of the policy with the opposite party. So the claim was repudiated on pre-existing disease under exclusions clauses of the policy. There is no deficiency in service on the part of the third opposite party.
Complainant is examined as Pw1and marked exhibit A1 to A8 from the side of the complainant. Padma Prabha who is the assistant manager legal of the opposite party filed proof affidavit in lieu of chief examination and marked exhibit B1 to B3 from the side of the opposite party.
On the basis of the contention of the rival parties we framed the following issues for consideration.
(1) Whether the opposite parties committed any deficiency in service as
alleged?
(2) Regarding the relief and costs?
Point number 1 and 2.
There is no dispute on the fact that the complainant had had availed a Medi classic Individual insurance policy vide policy numberr P1181113/01/2021/009584 valid from 23-11-2020 to 22-11-2021 for a sum insured of Rs.2,00,000.It is proved by exhibit A3 discharge summary that the complainant was admitted to SH Medical Centre hospital on 3-8-2021 for the treatment of Decompensated Anaemia Secondary to GI Blood loss and was discharged on 6-8-2021 with an advise of surgery for haemorrhoid. It is further proved by exhibit A3 that he had spent Rs.31,823/- at SH hospital for treatment expenses.
Exhibit A4 is the discharge summary issued by KIMS hospital . It is evident from Exhibit A4 that the complainant was admitted at Kims hospital, Thiruvananthapuram on 7-8-2021for the treatment of lower GI bleed and underwent Stapler Haemorrhoidectomy and after the treatment he was discharged on 10-8-2021. It is further proved by Exhibit A4 that the complainant had spent Rs.95,311 /-for the treatment expenses at the hospital.
The specific case of the complainant is that his policy is a switch over policy and it has got a continuity right from 25-11-2014. In order to prove his case the complainant produced A1 certificate issued by the New India Insurance company, wherein it is stated that the complainant had availed a Group Mediclaim Policy named Arogya Maitri from 25-11-2014 and he was under the coverage of the said policy without any interruption till 24-11-2020. On perusal of exhibit A2 policy we can see that there is no endorsement against the column of previous policy no. During cross examination Pw1 who is none other than the complainant deposed that he had signed Exhibit B1 proposal form and he did not need any assistance from others to fill up ExhibitB1. On perusal of exhibit B1 we can see that the complainant had answered in negative against the question whether he had any other insurance policy in the past or current. It is pertinent to note that though the complainant argued that his policy is a switched over policy from his previous insurer he did not adduce any evidence to prove the same. Moreover the complainant did not give any explanation for the non-production of the application for porting the policy from his previous insurer though he produced exhibit A1 . Hence Medi Classic insurance policy (individual) can be considered as a fresh policy and continuity benefits are not available to this policy.
According to the opposite party the treatment for which the complainant undergone was a pre –existing disease. The opposite party relied on exhibit A4 which is the Discharge summary issued by KIMS hospital wherein it is recorded that the complainant had complaints of occasional bleed per rectum (PR) since 4 to 5 years .
The claim of the complainant was repudiated by the opposite party on the ground that as per Exclusion No. IV(1)(A) of policy any pre-existing disease will be covered under the policy only after completion of 48 months continuous coverage. As per exclusion clause no. IV(2)(F)(11)of the policy condition the opposite party is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of Hemorrhoids during the first two year of continuous operation of the insurance cover.
On perusal of exhibit B1 we can see that the complainant had answered as ‘None’ to the question “do you have any health problem”. As discussed earlier Exhibit A4 proves that the complainant had complaints of occasional bleed per rectum (PR) since 4 to 5 years. Thus we are of the opinion that the complainant availed the policy by suppressing material facts regarding his health condition from the opposite party.
In the light of above discussion we are of the opinion that the complainant had failed to prove his case with cogent evidence and the complaint is liable to be dismissed. Hence the complaint is dismissed.
Pronounced in the Open Commission on this the 27th day of April, 2023
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Sworn statement from the side of complainant
Pw1 – Emil C. Varghese
Exhibits marked from the side of complainant’
A1 – Endorsement letter dtd.13-03-22 issued by New India Assurance Co. Ltd
A2 – Copy of policy issued by opposite party
A3 – Copy of discharge summary and reports issued by S.H. Medical Centre
A4 – Copy of discharge summary issued by KIMS hospital
A5 series – Doctor certificate and medical bills
A6 – Copy of repudiation letter dtd.08-11-21 issued by opposite party
A7 – Copy of letter by complainant to the Grievance Redressal Officer, Star Health
and Allied Insurance Co. Ltd.
A8 – Copy of letter by Grievance Redressal Officer
Exhibits marked from the side of opposite party
B1 – Copy of proposal form issued by opposite party
B2 – Copy of policy condition issued by opposite party
B3 – Copy of letter dtd.28-01-2022 issued by opposite party to petitioner
By Order
Sd/-
Assistant Registrar
