Order No. 22 dt. 04/07/2017
The case of the complainant in brief is that the complainant had the mediclaim policy with the o.p. The complainant regularly paid the amount towards the premium in respect of he said policy. The complainant all on a sudden became ill and he was admitted to B M Birla Heart Research Centre, Kolkata from 17.04.2013 to 22.04.2013 and he was diagnosed by the doctor with post PTCA status, hypertension and anemia. For having such treatment the complainant had to incur the expenses of Rs. 58,476.21. The complainant after recovery submitted bills to the o.p. for reimbursement of his medical bills. The complainant sent several letters to the o.p. to know the fate of those bills but the o.p. did not give any reply. Subsequently the complainant sent a letter to the o.p. through the Asstt. Manager, Claims Department but no effective step was taken by o.p.no.1 for which the complainant had to file this case. The complainant prayed for direction upon the o.ps for releasing the amount of Rs.58,476.21 and Rs.30,000/- for compensation and litigation cost of Rs.10,000/- .
The o.ps contested the case by filing a w/v denying all the material allegations of the complaint. It was stated that the policy provides daily benefit for each day admitted as an impatient for covered sickness/accident along with reimbursement of Accidental Medical expenses. The policy does not provide reimbursement of sickness medical expenses as claimed by the complainant. On examination of the documents submitted by the complainant it was observed in the discharge certificate issued by B M Birla Heart Research Centre, Kolkata dated 22.04.2013, the patient Sri Ashoke Kumar Simlai was admitted with post PTCA status c/o chest discomfort since four days H/O Malena since last four days, hypertension for four years PTCA done on 31.10.2008.
According to the discharge certificate and medical records the complainant had been suffering from hypertension since last 4 years and also underwent angioplasty on 31.10.2008 which is prior to policy inception date i.e. 26.06.2010. It was further stated that in terms of health care plan policy, Part-B General Exclusions of the policy “This policy does not provide benefit for any expenses incurred directly or indirectly in respect of (1) any pre-existing condition or any complication arising from it . The complainant suppressed the material fact of suffering from hypertension since last 4 years and also underwent Angioplasty on 31.10.2008. The policy is issued on the basis of good faith and if the complainant would have disclosed his illness at the time of applying policy the policy would not have issued to the complainant. In view of the said fact the insurance company did not allow the prayer of the complainant for releasing the medical reimbursement incurred by him. On the basis of the facts and circumstances stated above the o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the mediclaim policy with the o.p.at the relevant point of time?
- Whether withholding of the claim of the complainant tantamount to deficiency in service?
- Whether the complainant suppressed the pre-existing disease ?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
The Ld. Lawyer for the complainant argued that during the subsistence of the mediclaim policy issued by the o.p. the complainant became ill and he went to B M Birla Heart Research Centre, Kolkata for treatment. After examination by the doctor of the said hospital and as per the advice of the doctor some tests were done. On perusal of the reports the doctor advised for admission of the complainant in the said hospital. The complainant had been at the said hospital for treatment from 17.04.2013 to 22.04.2013. During his stay he was diagnosed for post PTCA status, hypertension and anemia. For undergoing such treatment the complainant had to incur an expenses of Rs.58,476.21. After recovery the complainant submitted the bills but the o.p. did not release the fund and no intimation was given to the complainant to that effect. On the basis of the said fact the complainant filed this case praying for direction upon the o.p. for releasing the said fund as well as for compensation and cost. The Ld lawyer for the complainant in support of his said contention relied on decision as reported in (1) 2016 CPJ 322(NC) wherein it was held that as per medical reports the policy holder was healthy, if the policy holder suffers illness after issuance of policy it cannot be said to suppression of facts.
The Ld lawyer of the o.p. argued that according to the terms and condition of the policy provides daily benefit for each day admitted as an impatient for covered sickness/accident along with reimbursement of Accidental Medical Expenses. On examination of the medical reports issued by the said hospital dated 22.04.2013 the patient Sri Ashoke Kumar Simlai was admitted with post PTCA status c/o chest discomfort since last 4 days h/o malena since 4 days , hypertension for 4 years, PTCA done on 31.10.2008. Since the complainant at the time of applying for policy suppressed the material fact of his pre-existing condition or any complication arising from those illness the claim of the complainant was not considered. It was further stated by the o.p.that o.p. is liable to pay to the extent of Rs.5,000/- ( 5 days @ Rs.1,000/- daily benefit after applying the deductible of one day) as per the terms and conditions of the policy which is payable under the coverage in hospital indemnity under sickness provided there is no violation of any terms and conditions of the policy. On the basis of the said fact the o.p. prayed for dismissal of the case.
Considering the submission of the respective parties it is an admitted fact that the complainant was the holder of mediclaim policy under the o.p. It is an admitted fact the complainant became ill and he got admission at B M Birla Heart Research Centre, Kolkata for treatment. It is also found from the materials on record that the complainant underwent PTCA on 31.10.2008 which is prior to policy inception date i.e. 25.06.2010. It is the incumbent duty of the complainant to disclose the pre-existing disease at the time of applying for obtaining policy. The complainant suppressed the said fact . The Ld. Lawyer for the complainant emphasized that after the admission in the hospital those diseases were detected and thereby on the basis of the judgement passed by Hon’ble NCDRC the complainant claim the reimbursement of the medical bills. On perusal of the said judgement we find that during the treatment some complications were found as such Hon’ble NCDRC held in support of the complainant. But here in this case from the materials on record it appears that at the time of admission in the said hospital it was disclosed that the complainant underwent PTCA on 31.10.2008 and he was also suffering from hypertension for 4 years. On the basis of the said fact because of suppression of material fact at the time of applying for obtaining policy the o.p. rightly did not allow the medical bills of the complainant . In this respect we can rely on a decision as reported in 2016(4) CPR 471(NC) wherein it was held that false or inaccurate statement by assured was on a material aspect which influenced decision of insurer on whether to accept proposal or not and it was further held that insurer was justified in repudiating claim on account of false statement made by assured in proposal form. Having regard to the said fact and also relying on the materials on record we hold that the o.p. did not commit any deficiency in service by not allowing the claim of the complainant. It is also relevant to mention here that the insurance company is agreeable to pay a sum of Rs.5,000/- to the complainant for taking admission in the said hospital. The complainant can apply to the o.p. for the said amount.
Thus all the points are disposed of accordingly.
Hence, ordered.
that the cc no.697/ 2013 is dismissed on contest without cost.
Supply certified copy of this order to the parties free of cost.
