By Sri. MOHANDASAN.K, PRESIDENT

Complaint in short is as follows:-

1.         The complainant availed insurance policy of the opposite party through the agent Mr. Nisanth during the year 2020 December. He paid premium of Rs. 13,145/- and subsequently he renewed the policy during the year 2021, 2022 and 2023. The insurance agent had assured cash less treatment facility at the time of availing the insurance policy. 2.    The complainant had disclosed all the treatment history undergone by him. He has stated surgery to his neck and surgery to his right shoulder. He had undergone surgery to the neck during the year 2013 from the Ganga hospital Coimbatore and thereafter there was continues review periodically. But there is no complication subsequent to the surgery. Thereafter during 2019 he met with a motor cycle accident and as a result there was rotator cuff tear to his right shoulder and for that he was undergone surgery from Moulana hospital, Peinthalmanna and Dr. Faizal did the surgery. All these facts were disclosed at the time of subscription of insurance policy. But later during 2022 in the September month while the complainant trying to cut and remove a branch of teakwood there were  strain to his shoulder and then on next month while he was visiting Ganga hospital for checkup Dr. Ajay Prasad was consulted and he prescribed certain medicines. There was some relief on use of the medicine but subsequently he met with Dr. Faizal Kareem from Moulana hospital on 07/04/2023 then he prescribed certain medicine and suggested MRI scan. He has taken MRI scan from EMS hospital and then it was revealed two cracks and then advised for surgery. Then he was again approached Ganga hospital on 20/04/2023 and as per the ortho specialist Dr. Sundarraj some medicines prescribed and thereafter 45 days he approached the Alshifa hospital Perinthalmanna the sports injuries specialist Dr. Abdul Kareem and he also advised for the surgery. In the light of similar advice by 3 doctors he undergone surgery on 07/08/2023. Even prior to the surgery the complainant intimated the insurance company on 13/07/2023 and prayed for cashless treatment. But the opposite party informed on 27/07/2023 that they are not ready to provide cashless facility and directed to approach for reimbursement. Accordingly the complainant approached the opposite party for reimbursement along with entire treatment records. Then the opposite party demanded for a self-declaration and that also was issued to the opposite party. But the opposite party repudiated the insurance claim on 26/09/2023 stating that the ailment is prior to the inception of insurance policy.

3.         The complainant specifically submitted that the insurance claim of the complainant is not at all related to the previous surgery and treatment and there is no connection with that treatment. Accordingly the complainant approached the opposite party again with certificate from the doctor who treated the complainant. But on 25/10/2023 they repeatedly sent reply stating the same reason for repudiation. According to them the treatment undergone by the complainant has got 9 years history. Hence complainant alleges deficiency in service and unfair trade practice on the side of opposite parties. The complainant alleged that the agent did not provide service to the complainant. Moreover, the opposite party alleged that the complainant colluding with opposite party and trying to extract money from the insurance company. The complainant submitted that he provided all the treatment records to the opposite party. The complainant  prayed 1,40,000/- towards hospital expenses, 1,00,000/- rupees towards financial  loss , 1,50,000/- towards mental agony and inconvenience Rs. 75,000/- towards cost of the proceedings i.e. altogether 4,65,000/-rupees.

4.         On admission of the complaint notice was issued to the opposite parties and the opposite parties entered appearance and filed version. The opposite party submitted the complaint is without any merit and with ulterior motive of making illegal gains.  

5.         The opposite parties admitted the complaint had taken a star  group health insurance  policy for bank customers from the company on 23/12/2020 covering the complainant , his wife and their children and the same has renewed up to 22/12/023 for a some insured of Rs 5,00,000/- vide policy No. P/181312/01/2023 /010276. At the time of availing policy the complainant was supplied the terms and conditions of the policy and the conditions of the policy were duly explained to the complainant at the time of proposing policy.

6.         The opposite party submitted the complainant had disclosed that he had underwent surgery for right shoulder on 25/02/2019 and surgery on neck bone on 18/09/2013 to the opposite party. Moreover the complainant had submitted previous records along with the proposal form. Based on the submitted proposal form and records, the opposite parties had issued the policy to the complainant with an endorsement “diseases of the musculoskeletal system and their complications, all complications related to the surgeries or procedures performed previously- rotator cuff tear surgery + cervical discectomy, diseases of vertebrae, disc and spinal code and their complications “as pre-existing diseases.

7.         The opposite parties submitted during the aforesaid policy period the opposite parties had received a request for cashless hospitalization from KIMS Alshifa health care private limited, Malappuram stating that the complainant was admitted at the hospital on 02/08/2023 and was provisionally diagnosed with left rotated cuff tear. In the duration of present ailment column of the pre-authorization request it is noted as one year.

8.         Hence the opposite parties issue a query letter dated 29/07/2023 to the hospital to revert with first consultation papers before one year with exact circumstances, first consultation papers immediately after the injury. As replay to the said query the hospital has replied that the complainant was first consulted at Ganga hospital on 20/04/2023 and there was no history of trauma. From the available document it is observed that the complainant has above disease which is a long standing ailment and the opposite parties were not in a position to ascertain the duration of the disease based on the submitted documents / details and requires further evaluation. Hence the opposite parties denied the pre-authorization request for cashless treatment and informed the above hospital and the complainant vide letter dated 31/07/2023.

9.         Thereafter the complainant submitted claim form with discharge summary, bills and reports for the re imbursement of treatment expenses. As per the discharge summary the complainant was admitted on 07/08/2023 for the treatment of full thickness supra spinatus tear + superior 3^rd interstitial subscapularis tear (L) shoulder and after treatment he was discharged on 09/08/2023. The treatment history revealed complaints of left shoulder pain since 1 year, trivial injury.        Hence the opposite parties issued a query letter dated 28/08/2023 to the complainant to submit first consultation papers, all past treatment details and the hospitalization records, investigation reports in previous hospitalization, previous right shoulder surgery hospitalization records, self-declaration letter stating detailed circumstance of injury with date, time and place.

10.       As per the insurance policy, pre-existing diseases is excluded under exclusion clause No.3 of the policy which states that “pre- existing disease as defined as in the policy until 36 consecutive months of continues coverage have elapsed since the inception of the first policy with the company “hence the claim was repudiated and the same was informed to the complainant vide letter dated 26/09/2023.

11.       Subsequent to the repudiation complainant submitted a request before the opposite parties to return the documents submitted by him. Hence the following documents-

(i) Original discharge summary, ( ii)  Original final / main bill , (iii )All other original  bills ,(iv) Original lab repot, (v) Original arthroscopy report,(vi) Echo cardiograph report, (vii) Original MRI scan report, (viii)  Original  TMT images, (ix)  Original  X-ray films 3 in number(x)original prescription was given to the complainant on 09/10/2023.

12.      The opposite party submitted that the complainant had taken the policy on 23/12/2020 and it was renewed only up to 22/12/2023 and he has not paid any premium during the year 2023.  Further the opposite party submitted that the opposite parties had explained to the complainant that the endorsed pre- existing disease are only covered after 36 months from the inception of the policy. As per the treatment records the treatment undergone for the complainant is for the pre-existing disease. Hence the insurance claim was repudiated as per the terms and conditions of the policy. The complainant has not suffered any mental agony due to the act of opposite parties. The complainant is not entitled for any relief as prayed in the complaint. Hence the prayer is to dismiss the complaint accepting the version of the opposite parties.

13.       The complainant and opposite parties filed affidavit and documents. The documents of the complainant marked as Ext. A1 to A8. The documents of the opposite party marked as Ext B1 to B10.  Ext. A1 is photo copy of discharge summary issued from Ganga Medical center and hospitals private limited for the treatment 17/04/2013 to 22/04/2013. Ext. A2 is copy of discharge summary issued from Moulana hospital Perinthalmanna for the period 25/02/2019 to 26/02/209. Ext. A3 is copy of certificate issued from KIMS Alshifa hospital by Dr. Abdul Khaleel P dated 10/10/2023. Ext. A4 is copy of letter issued by the opposite party regarding the denial of pre authorization for cashless treatment dated 27/07/2023. Ext. A5 is copy of self-declaration issued by the complainant to the insurance company nil dated. Ext. A6 is copy of discharge summary issued from Al shifa hospital for the period 07/08/2023 to 09/08/2023.  Ext.A7 is copy of details of insurance coverage.  Ext. A8 is copy of letter of repudiation of claim dated 26/09/2023. Ext.B1 is copy of proposal form dated 22/12/2021. Ext.B2 is copy of policy schedule and conditions dated 19/12/2022. Ext. B3 is copy of request for cashless hospitalization issued from KIMS Alshifa Health Care private limited dated 02/08/2023. Ext. B4 is copy of query letter dated 29/07/2023. Ext. B5 is copy of quarry replay dated 31/07/2023. Ext. B6 copy of denial of pre authorization for cashless treatment. Ext. B7 copy of discharge summary from KIMS Alshifa hospital dated 09/08/2023. Ext. B8 is copy of quarry letter dated 28/08/2023. Ext.B9 is copy of treatment records from KIMS Alshifa hospital Perinthalmanna. Ext. B10 copy of repudiation letter dated 26/09/2023.

14.       Heard complainant and opposite parties, perused affidavit and documents. The following points arise for consideration:-

1. Whether there is non- disclosure of pre-existing disease and treatments during first inception of insurance policy?
2. Whether the treatment undergone by the complainant was for   pre-existing disease?
3. Whether the complainant is entitled for the insurance claim?
4. Relief and cost?

15.       Point No.1 & 2

 The opposite party denied the insurance claim to the complainant stating non-

disclosure of pre-existing disease as per Ext. B6 and Ext.A8 respectively dated 31/07/2023 and 26/09/2023. The opposite party produced Ext.B1 and B2 respectively the proposal form for the insurance policy dated 22/12/2021 and certificate of insurance dated 19/12/2022.   Ext.B1 disclose details of pre-existing that surgery for neck bone on 18/04/2013 and surgery right shoulder on 25/02/2019.   Ext.B2 reveals pre-existing disease as diseases of the  musculoskeletal system and their complications, all complications related to the surgeries or procedures performed previously – rotator cuff tear + cervical  discectomy, diseases  of vertebra , disc and spinal code and their complications. Ext.B6 the pre authorization for cashless treatment dated 31/07/2023 stands denied with the endorsement that from the hospital records that the insured patient has the above disease which is long standing ailment and so the insurance company not able to ascertain the duration of the disease based on the documents submitted by the claimant and so it requires further evaluation. But the treatment record from the treated hospital KIMS Alshifa the diagnosis is full thickness supra spinatus tear + superior 3^rd interstitial subscapular is tear (L) shoulder. The procedure done there in the hospital is arthroscopic supra spinatues repair using double raw technic + subscapularis repair using 5.5 mm Suture anger done under SAB on 07/08/2023.  The clinical finding is that complaints of left shoulder pain since one year, trivial injury, gradually progressive, night discomfort more since three months.

 16.     The opposite party produced Ext.B10 dated 26/09/2023 stating the reason for the

repudiation of claim that on the examination of medical reports submitted by the complainant dated 03/10/2022 that the insured patient is on 9 years follow up for arthritis left shoulder which is  prior to inception of medical insurance policy.  Hence according to the opposite party the complaint diagnosed a pre-existing disease and the present admission and treatment of the insured patient is for the pre-existing disease.

17.       But the perusal of proposal form there is a proper disclosure of treatment and disease by the complainant. So the contention of non-discloser of pre-existing disease is baseless one. Now the question is whether the complainant undergone treatment for the pre-existing disease or not.

18.       The complainant produced Ext. A3 which was produced before the opposite party.  Ext. A3 is a certificate issued by Dr. Abdulla Khaleel, consultant orthopedic surgeon attached to KIMS Alshifa super specialty hospital Perinthalmanna dated 10/10/2023.  The certificate reveals as follows:-

TO WHOM SOEVER IT MAY CONCERN

This is to certify that Mr. Ummer K, 65 years old male (MRD No: 598819), was admitted under me with history of (L) shoulder pain since 1 year. He was treated with Arthroscopic supraspinatus repair & subscapularis repair on 07/08/2023. He has past history of (R) rotator cuff repair done from elsewhere in 2019 & cervical discectomy & fusion in 2013 from elsewhere and now asymptomatic. 1 year back on a regular visit for his neck surgery, he also complaints of pain in (L) shoulder. And the doctor there diagnosed clinically that Mr. Ummer has periarthritis shoulder (periarthritis is not arthritis). His left shoulder pain just started around that time and it has nothing to do with his old cervical spine disease. Hence your observation that (L) shoulder pain is since years and he has got (L) shoulder arthritis is improper. Please go through his case sheets and history once more before getting into conclusion.    

19.       Hence the treated doctor categorically denied the contention of the opposite parties. He has stated that the treatment undergone at present is nothing to do with his old cervical spine disease and there under.  If that be so there is no reason to accept the contention of the opposite party that the present treatment was for pre-existing disease which was not disclosed at the time of inception of insurance policy.

20.       Point No.3 and 4

            The complainant is admittedly has got insurance coverage of the opposite party during the relevant period. The complainant submitted that he subscribed the policy of the opposite party during the month December 2020. The opposite party admitted the same and according to opposite party the insurance policy was renewed up 22/12/2023 for a sum of Rs. 5, 00,000/- vide policy no. P/181312/01/2023/010276. Hence the complainant is entitled for the insurance claim from the opposite party.

21.       The claim of the complainant is that Rs. 1, 40,000/- towards hospital expense and 2, 50,000/- rupees as compensation and Rs.75, 000/- as cost of the proceedings.  The opposite party submitted details of documents including total expected cost of hospitalization Rs.1, 40,000/- dated 02/08/2023 at the time of admission of the complainant. The opposite party submitted in the version that the complainant submitted claim form for an amount of Rs. 1, 30,996/- rupees. It is further submitted that as per the submitted document the liability of the insurer was to be limited to 1, 15,950/-. Hence the opposite parties are directed to pay Rs.1, 15,950/-towards the treatment expense of the complainant. The complainant prayed huge amount as compensation and cost. The commission finds Rs. 50,000/- will be a reasonable amount as compensation on account of deficiency in service and thereby caused inconvenience and hardship to the complainant. The complainant also entitled cost of Rs. 5,000/-.

22.       In the light of the above facts and circumstances the complaint stands allowed as follows:-

1. The opposite parties are directed to pay Rs. 1, 15,950/- (Rupees one lakh fifteen thousand nine hundred and fifty only) to the complainant towards the treatment expense as insurance claim.
2. The opposite parties are directed to pay Rs. 50,000/- (Rupees fifty thousand only) to the complainant as compensation on account of deficiency in service and thereby caused inconvenience and hardship.
3. The opposite parties are directed to pay Rs.5, 000/- (Rupees five thousand only) to the complainant as cost of the proceedings.

The opposite parties shall comply this order within one month from the date of receipt of copy of this order, failing which the opposite party is liable to pay 9% interest for the above said entire amount from the date of order to till date of payment.  

Dated this 30^th day of October, 2024.          

Mohandasan. K, President

     Preethi Sivaraman.C, Member

     Mohamed Ismayil.C.V, Member

APPENDIX

Witness examined on the side of the complainant: Nil  

Documents marked on the side of the complainant: Ext.A1 to A8

Ext.A1: Photo copy of discharge summary issued from Ganga Medical centre and

             hospitals private limited for the treatment 17/04/2013 to 22/04/2013.

Ext.A2: Copy of discharge summary issued from Moulana hospital Perinthalmanna for the

             period 25/02/2019 to 26/02/209.

Ext A3: Copy of certificate issued from KIMS Alshifa hospital by Dr. Abdul Khaleel P

             dated 10/10/2023.

Ext A4: Copy of letter issued by the opposite party the denial of pre authorization for

             cashless treatment dated 27/07/2023.

Ext A5: Copy of self-declaration issued by the complainant to the insurance company nil

              dated.

Ext.A6: Copy discharge summary issued form Al shifa hospital for the period 07/08/2023

             to 09/08/2023.

Ext.A7: Copy of details of insurance coverage.

Ext.A8: Copy of letter repudiation of claim dated 26/09/2023.

Witness examined on the side of the opposite party: Nil

Documents marked on the side of the opposite party: Ext. B1 to B 10

Ext.B1: Copy of proposal form dated 22/12/2021.

Ext.B2: Copy of policy schedule and conditions dated 19/12/2022.

Ext.B3: Copy of request for cashes hospitalization issued from Issued from KIMS Alshifa

             Health Care private limited dated 02/08/2023.

Ext.B4: Copy of query letter dated 29/07/2023.

Ext.B5: Copy of quarry replay dated 31/07/2023.

Ext.B6: Copy of denial of pre authorization for cashless treatment

Ext.B7: Copy of discharge summary from KIMS Alshifa hospital dated 09/08/2023.

Ext.B8: Copy of quarry letter dated 28/08/2023.

Ext.B9: Copy of treatment records from KIMS Alshifa hospital Perinthalmanna.

Ext.B10: Copy of repudiation letter dated 26/09/2023.

Mohandasan. K, President

     Preethi Sivaraman.C, Member

     Mohamed Ismayil.C.V, Member