Date of filing: 26/02/2019
Date of Judgment: 10/07/2023
Mrs. Sashi Kala Basu, Hon’ble President.
This complaint is filed by Sri Sukesh Bhadra under section 12 of the Consumer Protection Act, 1986 against opposite parties (referred as OPs hereinafter) namely (1) Star Health & Allied Insurance Co. Ltd., Manager, Customer Care (2) Star Health & Allied Insurance Co. Ltd. Branch Office, Kolkata (3) Medica Hospital Pvt. Ltd. (4) Sri Khokan Basak and (5) Sri Rajat Das (Senior Manager and intermediate of OP 2 respectively) alleging deficiency in service on the part of OPs..
Case of the complainant in short is that he took health insurance coverage from Star Health & Allied Insurance Co. Ltd. being mediated by OP 4 in the year 2016. He had submitted a printed form along with declaration and paid the premium of Rs. 14,842/-. The insured sum was 2,00,000/-. The complainant was admitted in OP 3 hospital on 16/07/2017 at ICU and was discharged on 05/08/2017. As per the discharge summary issued by the Medica Hospital, complainant was suffering from (a) Septicimia Unspecified (b) other disorders of electrolyte and fluid balance, not elsewhere classified (c) Hypertension and (d) Acute renal failure, unspecified. It is specifically mentioned that the reason of admission for shortness of breath for two days and also mentioned that the 70 years old male has a history of Hypertension. Since the complainant was covered by mediclaim insurance provided by Star Health & Allied Insurance Co. Ltd. he submitted the claim before the OP 2 claiming the sum of Rs. 5,43,583/- paid by him towards his treatment. But the OPs failed to make any payment in spite of several representations. However OP 5 forwarded a message wherein complainant was asked to submit the additional documents / information. The Insurance Co. had demanded to submit documents of past consultation and treatments as he was a known case of Diabetes Mellitus. Complainant informed that there was no past history of diabetes mellitus. The complainant never felt shortness of breath prior to hospitalisation on 16/07/2016 and did not take any such treatment of Hypertension and Diabetes Mellitus. But the Insurance Co. did not pay any heed to his request and failed to provide the claim amount. It is the further case of the complainant that in the year 2017 complainant had undergone an eye operation for eye cataract and at that time, Insurance Co. had paid full amount towards the treatment as claimed by the complainant as it was small amount. Since the OP did not pay the claim amount, present complaint has been filed praying for directing the OPs to pay covered insurance sum along with interest, to pay compensation of Rs. 6,00,000/- and litigation cost of Rs. 50,000/-.
OP 1, 2, 4 & 5 have contested the case by filing written version contending specifically that the insured / complainant had submitted his claim along with field verification report of the said hospital i.e. Medica Super Speciality Hospital. It revealed from “Out Patient Assessment Nephrology” dated 01/09/2017 that the complainant had past history of Hypertension, temporal low developmental malformations and acute coronary syndrome. It is further contended that on scrutiny of the medical papers submitted by the complainant it was also observed that the complainant was admitted with the history of known case of Diabetes Mellitus. As the claim was made in the first year of policy coverage, OP Insurance Co. vide their letter dated 06/11/2017 asked the complainant to submit the medical documents of his all past consultation and treatment details of Diabetes Mellitus and Hypertension. But in spite of repeated reminder complainant did not submit those required document so Insurance Co. was constrained to repudiate the claim for want of additional documents vide its rejection letter dated 21/12/2017. The claim was repudiated as per the terms and conditions of the policy for non-submission of the required documents and for non-disclosure of the material fact regarding pre-existing disease of Hypertension and Diabetes Mellitus at the time of inception of the policy. So the OPs have prayed for dismissal of the complaint.
OP 3 has also contested the case by filing written version stating specifically that they have been unnecessary made a party in this case. Complainant was treated in the said hospital / OP 3 by a team of Doctors from the Department of Critical Care Unit, Cardiology and also general surgery. He was admitted on 16/07/2017 and was discharged on 05/08/2017 from the said hospital. No relief has been sought for against OP 3. So OP 3 prayed for rejection of the complaint.
During the course of the evidence, parties filed their respective examination in chief on affidavit followed by filing of questionnaire and reply thereto and ultimately argument has been heard. BNA is also filed on behalf of the complainant and OP 1, 2 4 & 5.
So the following points require determination:-
- Whether there was any suppression of material fact & non disclosure of pre-existing disease, by the complainant?
- Whether there has been any deficiency in service on the part of the OPs.
- Whether the complainant is entitled to the relief as prayed for?
DECISON WITH REASONS
All the three points being co-related are taken up together for discussion in order to avoid repetition.
It is an admitted fact that the complainant was covered by the Health Insurance Policy of OP 2 during the period of his medical treatment i.e. from 16.07.2017 to 05.08.2017 at Medica Super Speciality Hospital / OP 3. There is also no dispute that bill of Rs. 5,43,583/- was raised by OP 3 towards the treatment and complainant had submitted claim of the said amount from OP Insurance Co.
Apparently claim was rejected by the OP Insurance Company on two grounds. Firstly complainant failed to submit the required document of his consultations and treatment details of Diabetes Mellitus and Hypertension.. Secondly there has been suppression of pre-existing disease of Hypertension & Diabetes Mellitus by the complainant at the time of inception of policy violating thereby the terms and conditions of the policy. So the moot question to be considered is whether complainant had suppressed such alleged pre-existing ailments.
The best document to establish the same is the proposal form submitted by the complainant during the inception of the policy. Even though OP Insurance Co. has filed copy of said proposal form but it so illegible that it absolutely cannot be read. Due to the document being so illegible it is not cleared whether it is a complete proposal form? OP even though has specifically contended that complainant has suppressed such material fact and did not disclose it in the proposal form but for the reason best known to the OP Insurance Co., they have not filed the original proposal form or at least a legible copy of the same. It was althemore necessary because complainant has specifically claimed that he did not have any such disease of Hypertension and Diabetes Mellitus at the time of inception of policy or before his hospitalisation on 16.07.2017. The proposal form would have disclosed whether there was any such query which would have led complainant to disclose such alleged disease. In order to seek specific information from the insured, the proposal form must have specific questions so as to obtain clarity as to underlying risks in the policy.
Complainant has filed the discharge certificate wherein there is no mention of Diabetes Mellitus. First time it appears in the document “Out Patient Assessment Nephrology” dated 01.09.2017 i.e. after the complainant was discharged from OP 3. It is evident from the discharge summary that at the time of discharge, complainant was advised “Nephrologist opinion of HD twice / week till urine volume 2 litre / day followed”. So complainant visited the department of nephrology and consultant doctor N. Roy Chowdhury / Dr. D. Pahari on 12.08.2017 and thereafter on 01.09.2017. In the outpatient Assessment Nephrology dated 12.08.2017 there is no mention of past history of Diabetes Mellitus Type – 1. But on 01.09.2017 in the said document i.e. outpatient Assessment Nephrology, same doctors have recorded against past history Htn (Hypertension) T1DM (Type one Diabetes Mellitus). So neither in the discharge summary nor in the document of outpatient Assessment Nephrology, there is any mention about complainant having any past history of Diabetes Mellitus and since it has been stated only on 01.09.2017, same indicates that neither during the treatment while complainant remained admitted in OP 3 hospital nor when he went to Nephrologist on 12.08.2017 there was any such past history of Diabetes Mellitus which supports the claim of the complainant that he did not suffer from Diabetes Mellitus and so when asked to file documents of all past consultants and treatment details of Diabetes Mellitus, he could not submit the same.
Similarly in the document dated 12/08/2017 referred to above, Doctor did not write that there was any past history of Hypertension. However in discharge summary under the caption “Present History” it is recorded that the 70 years old male patient has history of Hypertension. Complainant was admitted for the reason of shortness of breath for two days and he was diagnosed septicaemia unspecified, other disorders of electrolyte and fluid balance not elsewhere classified, hypertension and acute renal failure unspecified.
OP Insurance Co. has filed copy of Insurance Policy namely “Senior Citizen Red Carpet Health Insurance Policy” where in it is mentioned against details of pre-existing diseases relating to the insured / complainant – “Nil”. It is already highlighted above that the proposal form submitted by the complainant filed by the OP is illegible and cannot be read. So there is no document before this commission to see whether there was any such specific query which could have led the complainant to disclose about his such alleged ailment of hypertension at the time of inception of policy. Said proposal form was also necessary as in the discharge summary it is mentioned “present history”. So it is not made cleared since when complainant had the problem of hypertension.
It is specific claim of the complainant that in the year 2017 he had undergone an eye operation for eye cataract and OP Insurance Company had paid the full claim amount. So it can safely be presumed that OP Insurance Co. did not find any past history that complainant was suffering from Hypertension or Diabetes Mellitus at that time. If complainant was suffering from hypertension since before inception of Insurance Policy and if there was any such past history of hypertension same would have been definitely recorded during the said eye operation because high blood pressure or hypertension needs to be treated before any such surgery is conducted. So payment of full claim amount by the OP Insurance Company to the complainant towards eye operation defies the contention of the OP about suppression of material fact or non-disclosure of pre-existing disease of hypertension and Diabetes Mellitus. In such a situation refusal of claim amount by the OP Insurance Co. either on the ground of suppression of material facts or on the ground of non-production of required additional documents of complainant’s past consultation and treatment details of Diabetes Mellitus and Hypertension, is nothing but unfair trade practice and deficiency in service on the part of the OPs 1, 2, 4 & 5 and thus they are liable to pay the said claim amount of Rs. 5,43,583/- which includes insured sum and compensation towards harassment & mental agony.
Hence,
ORDERED
CC/117/2019 is allowed on contest against OP 1, 2, 4 & 5 and dismissed against OP 3. Opposite parties barring opposite party No. 3 are directed to pay Rs. 5,43,583/- to the complainant within 60 (sixty) days from the date of this order. They are further directed to pay litigation cost of Rs. 12,000/- within the aforesaid period of 60 days. In default of payment entire sum shall carry interest at the rate of 7% p.a. till realisation.
