By Sri. MOHANDASAN.K, PRESIDENT
The complaint under section 12 of the Consumer Protection Act 1986.
- Complaint in short is as follows: -
The complainant is the policy holder of the opposite party and he was persuaded to subscribe the policy by the agent of the opposite party. The complainant and his family members are the beneficiary under the policy. He subscribed the policy of the opposite party in the year 2013 and thereafter he is renewing the policy on every year.
2. His policy No. is P/181323/02/2019/000038 and which is covered during the period 13/07/2018 to 12/07/2019 and the premium towards the policy was paid on 29/06/2018. The policy certificate was issued as customer code AA0002086551. The nominee under the policy was the wife of the complainant and the coverage provided as per the policy was Rs.5,00,000/-. As per the terms of the policy 5,00,000/- rupees were covered for the treatment on account of accident injuries or other ailments caused to complainant or his family members. All the terms were stated in the policy certificate and it was issued from the second opposite party office at Kottakkal.
3. The wife of the complainant was suffering from Uterus ailment and the same was informed to the opposite party on 10/08/2018. The opposite party issued an authorization letter for cashless treatment of the insured person worth Rs.25,000/- and it was assured to provide balance treatment expenses after completion of the treatment. On 13/08/2018 the wife of complainant was admitted in MIMS hospital Kottakkal and after the completion of treatment informed the opposite party. The treatment expenses were Rs.58,935/-. The MIMS hospital also informed the treatment details to the opposite parties on 14/08/2018. On the same day the opposite party issued a letter as information contending withdrawal of pre authorization sanctioned earlier. The opposite party also informed the complainant that the amount sanctioned Rs.25,000/- has been withdrawn and they are not in a position to allow the treatment expenses. The complainant came to know about the denial of the treatment expenses on 15/08/2018 at the time of clearing the discharge bill. The complainant submit that he is entitled to get the treatment expenses from the opposite party. He has stated that he admitted his wife in the hospital after information and obtaining consent from the opposite party. He has also stated that the opposite party has provided treatment expenses towards the similar disease of his wife. The allegation of the complaint is that the act of the opposite party amounts deficiency in service and unfair trade practice. The complainant has under gone financial difficulties and mental agony due to the act of the opposite parties and pray for the entire treatment expenses along with compensation of Rs.50,000/- and cost of Rs. 25,000/-.
4. On admission of the complaint notice were issued to the opposite parties and they appeared and filed version.
5. The contention of the opposite parties is that complaint is not maintainable either on facts or on law and liable to be dismissed with cost.
6. The opposite parties admits that the complainant had taken a family health optima insurance policy from the opposite party for the period 09/07/2014 to 08/07/2015 vide policy No.T/181312/04/2015/000082 for a sum of Rs.5,00,000/-and further renewed up to 12/07/2019 covering the complainant , his wife and three children . At the time of availing the policy the complainant was supplied with the terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with policy schedule.
7. In claim number CLI/2019/181323/0240894, the opposite parties received pre authorization request for cashless treatment from Aster Malabar Institute of Medical Sciences Hospital Malappuram which states that the wife of complainant Mrs. Suma was admitted at the hospital on 13/08/2018 and provisionally diagnosed with Uterine Fibroid / Menorrhagia. On receipt of pre authorization request from the opposite parties authorized initial amount of Rs.25,000/- on 10/08/2018 for the treatment of Uterine Fibroid / Menorrhagia. On 14/08/2018 the hospital authorities informed the opposite parties that the complainant was discharged on 14/08/2018 after the treatment and the hospital authority forwarded discharge summary. On verification of the discharge summary the treating doctor reveals that the patient was treated for Uterine Fibroid and underwent uterine fibroid embolizations on 13/08/2018. As per the terms and conditions of the policy the Uterine Fibroid embolization is not covered as per exclusion clause number 17 of the policy. As per the exclusion number 17 of the policy “ the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of expenses incurred of high intensity focused ultra sound, uterine fibroid embolization, Balloon Sinoplasty, Enhanced External Counter pulsation therapy and related Therapies , Chelation Therapy, Deep Brain Stimulation, Hyperbaric oxygen Therapy , Rotational field Quantum Magnetic Resonance Therapy , VAX- D, Low Level laser therapy, Photodynamic Therapy and such other similar Therapies”. Hence the opposite parties withdrawn the initial approval amount and the claim was rejected. The opposite party informed the same to the hospital authority and the complainant on 14/08/2018. The opposite party also submitted as per condition 3 and 4 of the policy the claim must be filed within 15 days from the date of discharge from the hospital and the insured person shall obtain and furnished company with all original bills, receipts and other documents upon which a claim is based. The complainant has not submitted the documents to the opposite parties for re imbursement at any stage for processing the claim based on policy terms and conditions.
8. The opposite party denied that the agent of the opposite party consulted the complainant and advised to take the policy are totally false and so denied. The contention of the opposite party is that the complainant approached them for availing a policy and the opposite parties as explained the terms and conditions of the policy and thereafter understanding the terms and conditions complainant opted the family health optima Insurance policy. The opposite party denied that the complainant was authorized an amount of Rs.25,000/- as advance and the opposite parties informed the complainant that the balance payment was approved under treatment. The opposite party submit that the hospital authority informed the opposite parties through pre authorization request form that the complainant’s wife was admitted for treatment for Uterine Fibroid and other details were not mentioned. The opposite parties sanctioned an amount of Rs.25,000/- on 10/08/2018 clearly mentioning in the authorization letter that the provisional cashless approval and the initial amount sanctioned are subject to review that any time and on receipt of further details / documents from you / or insured person. In case it is found that the claim is not admissible under the policy, the provisional cashless approval given and the initial amount sanctioned will be withdrawn by us. The hospital authorities forwarded the hospital documents to the opposite parties only on 14/08/2018 and after the verification of document it was found that the patient was treated for uterine Fibroid embolization and the same comes under exclusion clause number 17 of the policy. So, it was not payable as per terms and conditions of the policy and the same was informed the complainant.
9. The policy is issued strictly according to the terms and conditions and it is a settled law that the parties to the insurance contract are bound by the terms and conditions of the policy issued. The contention of the opposite parties that the complainant is not entitled to any relief stated in the complaint since there is no deficiency of service or unfair trade practice on the side of opposite parties. The complainant filed this complaint vexatiously and frivolously for the sole purpose harassing the opposite parties with intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guide lines of IRDA controlled by the Government of India. The company must exercise abundant caution in dealing with claims by applying all conditions correctly and so the complaint is liable to be dismissed with cost and compensation to the opposite parties.
10. The complainant and opposite parties filed affidavit and documents. Documents marked on the side of complainant is Ext. A1 to A7. Ext. A1 is request for cashless hospitalization or medical insurance policy. Ext. A2 series are withdrawal of pre authorization for cashless treatment and withdrawal of pre authorization sanctioned earlier. Ext. A3 series are medical bills issued from Malabar Institute of Medical Sciences Kottakkal Ext. A4 series is copy of bill assessment sheet for hospital payment. Ext. A5 series are the copy of the family health optima insurance plan policy schedule. Ext. A6 is extract of summary of recommendations on treatment. Ext. A7 is bill assessment sheet for hospitalization expenses along with treatment certificate issued by Dr. Tahsin Neduvanchery M.D, MRCP (UK), DM (Cardiology), FRCP (Edin), FACC, HOD and Chief Consultant Interventional Cardiologist, Aster MIMS Kottakkal. Documents marked on the side of opposite party as Ext. B1 to B7. Ext. B1series are documents including letter issued to the complainant by the opposite party and policy details. Ext. B2 is copy of customer information sheet of family health optima insurance plan (UID: IRDAI/HLT/SHAI/P-H/V.III/129/2017-18. Ext. B3 is copy of request for cashless hospitalization for medical insurance policy. Ext. B4 is authorization letter for cashless treatment of the insured person dated 10/08/2018. EXT. B5 is copy of discharge summary dated 14/08/2018 issued from MIMS, Kottakal, Ext. B6 is letter of withdrawal of pre authorization sanctioned earlier dated 14/08/2018. Ext. B7 is copy of rejection for pre authorization for cashless treatment. The complainant side examined Dr.Tahsin Neduvanchery as PW1.
11. Heard both side perused affidavits and documents and also the notes of arguments filed by the complainant.
12. The following points arise for consideration: -
1) Whether complainant is entitled for insurance coverage?
2) Whether there is deficiency in service on the part of opposite parties?
3) Relief and cost.
13. Point No.1 and 2
The grievance of complainant is that his wife underwent treatment for Uterus fibroid at Aster MIMS hospital at Kottakkal. There was an insurance policy in favor of the complainant family which was incepted during the year 2013. The said policy was continuously renewed by the complainant. At the disputed period of insurance was 13/07/2018 to 12/07/2019 which was covered by policy No. P/181323/02/2019/000038 and as per the terms of the policy the complainant and his family is covered. He paid premium towards the renewal on 29/06/2018. As per the policy the limit for the coverage was Rs.5,00,000/-. The wife of the complainant admitted in the hospital on 13/08/2018 and she was discharged from the hospital on 14/08/2018. Before the admission on 10/08/2018 complainant approached opposite parties and on the same day the opposite parties issued authorization for cashless treatment of insured person. As per the authorization it was informed that they had issued 25,000/- rupees to the hospital towards treatment expanse in advance. On 14/08/2018 the complainant and hospital authorities informed by the opposite parties that the pre authorization sanction has been withdrawn. The submission of the complainant is that he is entitled for the treatment expenses and the acts of the opposite parties amounts deficiency in service.
14. The contention of the opposite parties that as per the exclusion clause No.17 of the policy, the opposite parties are not liable to make payment towards treatment Uterine Fibroid embolization. The opposite party also contended that the complainant has not filed claim within 15 days from the date of discharge from the hospital. The opposite party produced documents Ext. B1 to B7. Ext. B2 is the document related to customer information sheet family health optima insurance plan. Even though there is no specific date mentioned in the document, it can be perused as a document issued during the period 2017-2018, which is applicable to the present issue. The said document clause 17 of exclusions include uterine Fibroid embolization . The clause read as follows: -
“The company shall not liable to make any payment under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of:-
- Circumcision, preputioplasty, Frenuloplasty, Preputial Dilatation and Removal
of SMEGMA.
- Inoculation or Vaccination (except for post –bite treatment and for medical
treatment for therapeutic reasons)
3. Congenital External Condition / Defects/Anomalies
4. Dental treatment surgery unless necessitated due to accidental injuries and
requiring hospitalization. (Dental implants are not payable)
5. Convalescence, general debility, run – down condition or rest cure, nutritional
deficiency states.
6. Psychiatric, mental and behavioral disorders.
7. Intentional self-injury
8. Use of intoxicating substances, substance abuse, drugs / alcohol, smoking and
tobacco chewing
9. Venereal Disease and sexually transmitted Diseases.
10. Injury / disease directly or directly caused by or arising from or attributable to
war invasion, act of foreign enemy, war like operations (Whether war be
declared or not)
11 Injury or disease directly or directly caused or contributed to by nuclear
weapons / materials.
12. All expenses arising out of any condition directly or indirectly caused due to
or associated with Human T-cell Lymph Trophic Virus type III (HTLV-III) or
Lymphadenopathy Associated Virus (LAV) or HIV/AIDS. It is however made
clear that such of dose who are positive for HIV (Human Immune Deficicneny
Virus) would be entitled for expenses incurred for treatment other than for
opportunistic infections and for treatment of HIV/AIDS, provided at the time
of first commencement of insurance under this policy, their CD-4 count is not
less than 350.
13. Treatment arising from or traceable to pregnancy, childbirth, family planning,
miscarriage, abortion and complications of any of these (other than
ectopic pregnancy)
14. Treatment for Sub – Fertility, Assisted Conception and or other related
complications of the same except to the extent covered under 1S.
15.Expenses incurred on weight control services including surgical procedures
such as Bariatric Surgery and /or medical treatment of obesity.
16.Medical and / or surgical treatment of Sleep apnea, treatment for genetic and
endocrine disorders.
17. Expenses incurred on High Intensity Focused Ultra Sound. Uterine Fibroid
Embolization, Balloon Sinuplasty, Enhanced External Counter Pulsation Therapy
and related therapies, Chelation Therapy, Deep Brain Stimulation, Hyperbaric
Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy,
VAX-D, Low level laser therapy, Photodynamic therapy and such other
Therapies similar to those mentioned herein under exclusion no 17”
15. The complaint on the other side produced Ext. A5 series which includes customer information sheet family health optima insurance plan. Though the document does not reveal any specific date on perusal it can be seen that it is issued for the period 2014-2015. In that document there is no such clause as stated by the opposite party in document B2. So, it can be seen that there is considerable difference in documents related to family health optima insurance plan. In this case the complainant became the part of the scheme during the year 2013. The complainant was regularly renewing the policy without any lapse. It can be seen that the complainant remitted his premium towards the last policy period on 29/06/2018 itself. His policy actually to be renewed only on 13/07/2018. The opposite party has got a contention as per B1 series there is 15 days free looking period to revert any proposal on variation in the insurance coverage. But on perusal of Ext. B1 it has been created by the opposite party on 12/07/2018. That means the opposite party prepared a letter in favor of the complainant informing look in period of 15 days after the remittance of premium for the renewal. The complainant was renewing the policy from 2014 onwards under the impression that he and his family are covered medical expenses by the insurance policy. The opposite party is bound to issue prior notice to the policy holder while renewing a policy if there is any considerable change in the coverage of insurance. There is no document to show the opposite party had brought to the notice of complainant regarding the terms and conditions incorporated in B2 document.
16. Insurance is a contract with the principal of uberrimafides i.e., at most good faith by the parties. In this complaint there is no allegation of suppression of any material fact by the complainant. The complainant approached opposite party in advance to the treatment and obtained prior sanction to undergo the treatment. On the other side the opposite party did not inform the complainant about the variation of the terms and conditions for the insurance coverage. But has given an authorization letter to the hospital availing advance amount of Rs.25,000/- for the reported disease. The complainant in good faith underwent treatment in the hospital and produced details of treatments before the opposite party. But at that time the opposite party denied the insurance coverage. So, it can be seen that the complainant acted in good faith but the opposite party suppressed the varied facts regarding the terms and conditions for the treatment from the complainant. The opposite party was aware the complainant undergoing treatment for the uterine fibroid and if the opposite party was cautious, they could have brought to the notice of complainant or the hospital that there is no coverage for uterus fibroid embolization. Exhibit B4 is the authorization letter issued to the hospital by opposite party. There is no specific exclusion of uterine fibroid embolisazion treatment. That the mode of treatment was not opted by the complainant but the doctor who treated the complainant decided the procedure to be followed in the given situation. The doctor had issued a certificate mentioning the treatment which the insured meant to undergo. It is correct that the doctor has not mentioned the mode of treatment to be followed. If the doctor were aware of the restrictions on mode of treatment, he could have followed another method. More over the Doctor knows that the opposite party had issued insurance coverage for the similar treatment earlier. The complainant examined the doctor who treated the wife of the complainant as PW1. He has deposed that uterine fibroid embolization ഇതിന് മുമ്പ് treat ചെയ്ത patient ന് star health approval കൊടുത്തിട്ടുÙ®. Ext. A4 എ¨¼ കാണിച്ചത്. ഇത് പ്രകാരം Arifa എ¼ രോഗിക്ക് ഈ Insurance coverage നുqq Procedure ചെയ്തു. ആയത് Star health നിന്ന് കിട്ടിയിട്ടുണ്ട്. സുമ എ¼വരുടെ അതേ അസുഖത്തിനാണ് Arifa എ¼വര് treatment തേടിയത്.
17. ഞങളുടെ hospital Multi Specialty hospital ആണ്. ഓരോ ചികിത്സക്കും പ്രത്യേകം പ്രത്യേകം department കള് ഉണ്ട് . ഞങളുടെ hospital – ലില് ഓരോ രോഗത്തിനും treatment ന് വരു¼വര് പല specialist കള് നോക്കുന്ന അവസരം വരാറു ണ്ട് . Ext. A7 series ആരുടെ ആവശ്യപ്രകാരം ആണ് കൊടുത്തത്? രോഗിയുടെ ആവശ്യപ്രകാരം ആണ് കൊടുത്തത് . Ext. A7 page –ല് Letter ന് എന്ന് issue ചെയ്തു എ¼ date ഇല്ല. Ext. A7 series 4 പേജ് എല്ലാ കാര്യങ്ങളും സുമ എന്ന രോഗിയുടെ ആവശ്യപ്രകാരം issue ചെയ്തതാണ് . ഞാന് Arifa എ¼ രോഗിയുടെ അനുവാദത്തോടു കൂടിയാണ് പേര് mention ചെയ്തത് . അതിന് രേഖകളില്ല . Consent Letter വാങ്ങിയിട്ടില്ല. എനിക്ക് oral permission ഉണ്ട്. Uterine fibroid embolization treatment ഏകദേശം 10 വര്ഷമായി ഇന്ത്യയില് പ്രചാരത്തില് വ¼¢ട്ട്. Uterine Fibroid എ¼ അസുഖത്തിന് വേറെ treatment ഉണ്ട്. Medical treatment ഉം surgical treatment ഉം ഉണ്ട്.
18 The witness also submitted that they commence the treatment after the approval of opposite party. Prior to approval, the hospital is not able to understand whether there is insurance coverage or not. The witness also added that this mode of treatment uterus fibroid embolization is a public issue and that reason also he was led to depose before the commission. So, it can be seen that there was no prior information to the complainant regarding the variation in terms and conditions of treatment policy. There was prior approval for the treatment by the opposite party. The opposite party did not care to inform the hospital authorities that uterine fibroid embolization is an exempted category of the treatment by the company. The opposite party had given consent for the complainant. So, it can be seen that from the documents and evidences there is deficiency in service and unfair trade practice on the part of the opposite parties. The complainant produced a decision pronounced by the Hon’ble Apex court of our country in civil appeal number 6778 of 2013 which is delivered on 09/12/2021.The decision considers the impact of non-communication about the variation of terms and conditions in an insurance policy.
19. The decision considering the relevant decisions rendered on this issue. In short, if the renewed contract is agreed, in all respect by all parties, undoubtedly the fresh terms (with restricting) would be binding however that would not be the case in a new term is introduced unitarily about. It is also noted that just before the renewal, premium was furnished the insurer or his agent was under the duty to alert the insured the change in terms which likely to impact their decision. The failure to inform the policy holders about the limitations resulted deficiency in service.
20. In this complaint as stated by PW1 and as stated by the complainant during the argument that they were at liberty to opt any other mode of treatment instead of uterine fibroid embolization or would have approached any other government hospital wherein sometimes treatment will be less expensive. The act of the opposite party caused the present situation and thereby the complainant suffered financial and mental agony. Hence, we find that the complainant entitled for the treatment amount as per the policy and also for compensation on account of deficiency in service and thereby caused financial loss and mental agony.
21. Point No.2
The wife of the complainant spent two days in the hospital as part of treatment and he has produced medical bills worth Rs.58,935/-. The opposite parties liable to pay the treatment expenses. The complainant prays a compensation of Rs.50,000/- on account of deficiency in service and financial loss thereby incurred by the complainant. Claim of the complainant is rupees 50,000/- on that account. The commission finds that it is reasonable claim and so we allow the prayer of compensation. His claim for cost we consider 20,000/- as reasonable amount. In the above facts and circumstances, we allow the complaint as follows: -
- The opposite parties are directed to pay Rs.58,935/- to the complainant as the hospital expenses incurred by the complainant.
- We direct the opposite parties to pay Rs.50,000/- as compensation on account of deficiency in service and there by caused financial loss and mental agony.
- The opposite parties are also directed to pay Rs.20,000/- 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 complainant is entitled 12% interest on entire above said amount from the date of this order till realization.
Dated this 18th day of February, 2022.
MOHANDASAN.K, PRESIDENT
PREETHI SIVARAMAN.C, MEMBER
APPENDIX
Witness examined on the side of the complainant: PW1
PW1: Dr.Tahsin Neduvanchery .
Documents marked on the side of the complainant: Ext.A1to A7
Ext.A1: Copy of request for cashless hospitalization or medical insurance policy.
Ext.A2: Series are withdrawal of pre authorization for cashless treatment and withdrawal
of pre authorization sanctioned earlier.
Ext A3: Series are medical bills issued from Malabar Institute of Medical Sciences
Kottakkal
Ext A4: Series is copy of bill assessment sheet for hospital payment.
Ext A5: series are the copy of the family health optima insurance plan policy schedule.
Ext A6: Extract of summary of recommendations on treatment.
Ext A7: Bill assessment sheet for hospitalization expenses along with treatment certificate
issued by Dr. Tahsin Neduvanchery M.D, MRCP (UK), DM (Cardiology), FRCP
(Edin), FACC, HOD and Chief Consultant Interventional Cardiologist, Aster MIMS Kottakkal.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B7
Ext.B1: series are documents including letter issued to the complainant by the opposite
party and policy details.
Ext.B2: Copy of customer information sheet of family health optima insurance plan (UID:
IRDAI/HLT/SHAI/P-H/V.III/129/2017-18.
Ext.B3: Copy of request for cashless hospitalization for medical insurance policy.
Ext.B4: Authorization letter for cashless treatment of the insured person dated
10/08/2018.
Ext.B5: Copy of discharge summary dated 14/08/2018 issued from MIMS, Kottakal,
Ext.B6: Letter of withdrawal of pre authorization sanctioned earlier dated 14/08/2018.
Ext.B7: Copy of rejection for pre authorization for cashless treatment.
MOHANDASAN.K, PRESIDENT
PREETHI SIVARAMAN.C, MEMBER
