By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get reimbursement of hospital bills from the opposite parties.
2. Brief of the complaint:- The complainant took a mediclaim insurance policy from the first opposite party through their authorized representative Mr. Vinayan.T vide Policy No:P/181314/01/2015/000678 for the period 30.05.2014 to 29.05.2015. The policy termed as Senior Citizens Red Carpet Insurance Policy covers claims of the insurer except those specifically excluded in the policy. A sum of Rs.5000/- was paid towards the premium and the premium amount was collected by the above said agent Mr.Vinayan T. On 21.01.2015 the complainant suffered from severe swelling in right leg and was admitted at Jubilee Mission Medical College Hospital Thrissur for diagnosis and treatment. The cause of the pain was diagnosed as Cellulitis of right leg, CAD and CKD. Fasciotomy and slough excision was done on 21.01.2015 and 30.01.2015. Cardiology consultation was done for fitness during the hospitalization term. Complainant was discharged on 27.01.2015. The hospitalization claims were submitted through the agent Mr. Vinayan. T on 09.02.2015. The Petitioner was again admitted on 12.02.2015 for follow up treatment and the reimbursements for the said claims were submitted by the end of February through the authorized agent, Mr Vinayan. The complainant alleged that the opposite party without any legally sound reason repudiated the claim. Being aggrieved from the repudiation of the claim the complainant raised this consumer dispute.
3. The complaint has been resisted by the opposite party by written version stating that the complainant had taken the policy named Senior Citizens Red Carpet Insurance Policy from this Opposite Parties for the period from 30.05.2014 to 29.05.2015 vide policy No.P/181314/01/2015/000678 for a sum insured of Rs.1,00,000/-. At the time of availing the policy the complainant was supplied with the Terms and Conditions of the policy. It is submitted that in case of Senior Citizen Red Carpet Insurance Policy medical examination is not required as the entry age must be above 60 years of age. As per terms and conditions of the Senior citizen Red Carpet policy issued to the complainant, only those Pre-existing diseases which are specifically declared by the proposer in the proposal form are covered under the policy. So it is compulsory that the information regarding the health must be provided in the proposal form, for the opposite party to provide coverage with suitable co-payment, ie, 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. It is submitted that Proposal form is the basis of insurance contract, on that basis the policy is issued. In the proposal form, the complainant has specifically declared that he was not suffering from any disease or ailment at the time of submitting the proposal form or any point of time earlier and that his health condition was good in all respects. In the proposal form, the complainant further declared that if after the insurance policy is effected, any particulars stated in the proposal form are found incorrect. the insurance company would incur 'no liability' under the policy. It is submitted that the complainant had intimated 2 claims to the opposite party for his hospitalization in Jubilee Mission Hospital, Thrissur on 18.01.2015 and K.G.Hospital, Coimbatore on 12.02.2015. In claim No.239073, the Opposite Party received pre authorization request from Jubilee Mission Hospital, Trissur on 18-1-2015 stating that the complainant was admitted at the hospital and was provisionally diagnosed with Cellulitis (R) lower leg with Superficial necrotising Fascitis. On receiving the pre authorization, the Opposite Party had issued a query letter dated 19.01.2015 directing to forward the first consultation of the insured. In response to the above requests, Hospital had sent certain documents but the documents were not sufficient enough to decide the claim of the complainant on merit. The opposite parties were therefore left with no other alternative but to deny the cashless facility on 20.01.2015 and had directed the complainant to submit the claim form with all records after discharge. It is submitted that the complainant after discharge had submitted a complete claim form with discharge summary and bills. As per the treatment records it is seen that the complainant is a known case of CAD/CKD and he had history of hypertension. Moreover on enquiry the complainant himself admitted that he IS on medications for hypertension since 3 years. As the complainant had not revealed the past medical history of hypertension, it amounts to Suppression of Material Facts which makes the contract void ab initio. It is submitted that insurance contracts are "contracts of uberime-fide". The opposite party issued the aforesaid policy on good faith based on the declaration made by the proposer/insured in the proposal form. So the company repudiated the claim due to Suppression of material facts and informed the complainant vide letter dated 08.06.2015. In Cl No.260361, the opposite party had received pre-authorization request from K.G.Hospital, Coimbatore on 12.02.2015 stating that the complainant was admitted at the hospital and was provisionally diagnosed with Large unhealthy ulcer right leg and also forwarded case sheets. In the case sheet forwarded by the hospital it is clearly recorded that the patient had a history of hypertension for 3 years. Moreover it was clear that patient is known case of hypertension and CAD/CKD and he is on medication. Hence the cashless request was denied and the same was informed to the hospital on 14.02.2015. The Complainant thereafter had submitted a complaint to the Opposite Party and considering the same as an appeal to the decision of repudiation by the Opposite Party, this opposite Party had reopened the claim and had verified the same. But as the complainant had himself admitted that he was under medication for Hypertension since three years, which is confirmed by the indoor case sheets of K.G.Hospital, the grievance cell upheld the decision of the Opposite party Company and forwarded the decision to the complainant on 21.07.2015. The allegations raised by the complainant in the complaint have already been answered above the remaining are denied. The opposite party had rightfully rejected the claim of the complainant. The opposite party had acted only as per the terms and conditions of the policy. The repudiation made by the opposite party was as per the terms and conditions of the policy and hence there is no deficiency of service or negligence on the part of opposite party.
4. Complainant filed proof affidavit and examined as PW1. Ext.A1 to A9 documents were marked. Opposite party is examined as OPW1 and Ext.B1 to B15 documents were marked. Out of which Ext.B8 letter given by the complainant to the opposite party was marked with objection. Ext.A1 is the Authorization Letter, Ext.A2 is the Senior Citizens Red Carpet Insurance Policy-Schedule. Ext.A3 is the IP Receipt dated 02.02.2015. Ext.A4 is the Copy of Discharge Summary. Ext.A5 is the Copy of letter dated 09.05.2015. Ext.A6 and A7 are the copy of letters send by the complainant to opposite parties dated 02.06.2015 and 29.06.2015. Ext.A8 is the Reply letter dated 15.07.2015. Ext.A9 is the Copy of letter dated 21.07.2015. Ext.B1 is the Senior Citizens Red Carpet Insurance Proposal form. Ext.B2 is the copy of is the Senior Citizens Red Carpet Insurance Policy-schedule. Ext.B3 is the copy of Pre-authorization request form. Ext.B4 is the Query on Pre-authorization dated 19.01.2015. Ext.B5 is the copy of Denial of Pre-authorization for cashless Treatment dated 20.01.2015. Ext.B6 is the copy of Claim Form. Ext.B7 is the copy of Discharge Summary. Ext.B8 is the copy of letter. Ext.B9 is the copy of Claim Repudiation Letter dated 08.06.2015. Ext.B10 is the Copy of Letter received from complainant dated 02.06.2015. Ext.B11 is the copy of Reply Letter dated 21.07.2015. Ext.B12 is the Copy of Request for Cashless Hospitalization for Medical Insurance Policy. Ext.B13 is the copy of Query on Pre-authorization dated 14.02.2015. Ext.B14 is the copy of Denial of Pre-authorization for cashless Treatment dated 14.02.2015. Ext.B15 is the Authorization Letter dated 26.06.2017.
5. On perusal of complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?.
2. Relief and Cost.
6. Point No.1:- The first question which arise for consideration is as to whether there is any concealment of pre-existing history of HTN in the Proposal form. Complainant has submitted two claim forms to the opposite party for reimbursement of medical expenses, but opposite party repudiated the claim of the petitioner on the ground that the complainant was suffering from HTN since 3 years and the policy had been taken suppressing the fact of such illness and there was ''suppression of material facts''. Through Ext.A5 dated 09.05.2015 opposite party requested for discharge summary at the time of CAD/CKD, and previous treatment details diagnostic/investigation reports. Later on 29.06.2015 through Ext.A7 complainant replied about it. Thereafter opposite party repudiated complainant's claim through Ext.A8 and A9 stating that the complainant is under medication for last 3 years for BP and it is not declared in Proposal Form while taking policy. To substantiate their contention opposite party argued relaying on Discharge Summary (Ext.A4) where in history and diagnosis columns it is stated that ''CAD/CKD/HNT''. While cross-examining OPW1 deposed that the reason for the repudiation of claim is that ''complainant is under medication for HTN since past 3 years as per the records from KG Hospital, Coimbatore and the repudiation made by the opposite party was as per the terms and conditions of the policy. It is really a case of non-disclosure and suppression of material facts then the insurance contract becomes void from the beginning and the complainant is not liable to indemnify the insured and there is no deficiency of service on the part of them.
7. PW1 deposed that he was not aware of the HTN while joining the policy. In Ext.A4 Discharge Summary no where mentioned that there is a history of HTN since past 3 years. Treatment record from KG Hospital Coimbatore has not been produced before the Forum. Opposite party produced photocopy of a letter (Ext.B8) alleged to be given by the complainant to opposite party to prove the history of HTN since 3 years. But complainant vehemently objected in marking this letter since it is a photocopy and challenged its genuinity also but opposite party failed to produce the original of this objected document (Ext.B8 marked with objection) to over rule the objection.
8. On consideration of the evidences and evaluation of the terms and conditions of the insurance policy it appears that regarding the second claim opposite party asked for records of previous treatment and investigation reports. But complainant could not produce that same, rather he replied through Ext.A7 that there is no such pre-existing history of disease while taking the policy, so as opposite party failed to produce the relevant documents from KG Hospital Coimbatore showing the history of pre-existing disease. Hence there is no reason to go behind the 'concealment of material facts'. The policy taken by the complainant being a senior citizens Red Carpet Policy there is no bar in getting a policy if there is the history of pre-existing disease. Hence the suppression of material facts does not arised in this case. Hence we opine that there is no violation of insurance contract on the part of the complainant and the repudiation of claim on the part of opposite parties are without any valid reasons and the opposite parties contention of suppression of pre-existing disease stands not proved. Hence opposite parties are deficient in providing their service to the complainant. Point No.1 is found accordingly.
9. Point No.2:- Since the Point No.1 is found in favour of complainant, he is entitled to get reimbursement of hospital bills from opposite parties with cost and compensation. The Point No.2 is decided accordingly.
In the result, the complaint is partly allowed and opposite parties are directed to pay the 70% of the claim amount in claim No.239013 and claim No.260361 as per the terms and conditions of the policy. Opposite parties are also directed to pay Rs.2,500/- (Rupees Two Thousand and Five Hundred) as compensation and Rs.2,500/- (Rupees Two Thousand and Five Hundred) as cost of the proceedings to the complainant. Opposite parties are also directed to take back the original claim form and supporting documents from the Forum produced by them as per the Order in I.A.144/2017. This Order must be complied by the opposite parties within one month from the date of receipt of this Order. Failing which the complaint is entitled for an interest at the rate of 10% per annum for the whole amount till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 7th day of August 2017.
Date of Filing:29.12.2016.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. IndiraKumari. Housemaid.
Witness for the Opposite Parties:-
OPW1. Balu. Executive (Legal) Star Health and Allied insurance Company.
Exhibits for the complainant:
A1. Authorization Letter. Dt:05.05.2017.
A2. Senior Citizens Red Carpet Insurance Policy-Schedule.
A3. Copy of IP Receipt.
A4. Copy of Discharge Summary.
A5. Copy of Letter. Dt:09.05.2015.
A6. Copy of Letter. Dt:02.06.2015.
A7. Copy of Letter. Dt:29.06.2015.
A8. Reply Letter. Dt:15.07.2015.
A9. Reply Letter. Dt:21.07.2015.
Exhibits for the opposite parties:-
B1. Copy of Senior Citizen's Red Carpet Insurance Proposal Form.
B2. Copy Senior Citizens Red Carpet Insurance Policy-Schedule.
B3. Copy of Pre-authorization Request Form.
B4. Copy of Query On Pre-Authorization. Dt:19.01.2015.
B5. Copy of Denial of Pre-Authorization for Cashless Treatment. Dt:20.01.2015.
B6. Copy of Claim Form.
B7. Copy of Discharge Summary.
B8. Copy of Letter.
B9. Copy of Repudiation Letter. Dt:08.06.2015.
B10. Copy of Letter. Dt:02.06.2015.
B11. Copy of Reply Letter. Dt:21.07.2015.
B12. Copy of Request for Cashless Hospitalization for Medical
Insurance Policy.
B13. Copy of Query on Pre-Authorization. Dt:14.02.2015.
B14. Copy of Denial of Pre-Authorization for cashless Treatment. Dt:14.02.2015.
B15. Authorization Letter. Dt:26.06.2017.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
