ORDER
Per Sh. Rakesh Kapoor, President
In the year 2003, the complainant had subscribed to mediclaim insurance policy from M/s National Insurance Company Ltd. He had renewed the policy from time to time till 12.6.2012. W.E.F. 12/6/2012 he had shifted to the mediclaim policy floated by OP1 which was effective for the period 12-6-2011 to 12-6-2012. On 12-02-2012, the complainant was admitted to Sir Ganga Ram owing to severe pain in the right lower limb . He was discharged from the hospital on 25.2.2012 and had incurred a sum of Rs 301596/- as expenses on the
treatment. He had filed a claim with the OP1 for reimbursement which was repudiated vide letter dated 1.5.2012. It is alleged by the complainant that the repudiation of the claim was illegal and unjustified. Hence, the complaint.
OP1 has contested the complaint and has filed a written statement. It has denied any deficiency in service on its apart and has justified the repudiation of the claim on the plea that it was in accordance with the terms and conditions of the insurance policy. Para 2 of the preliminary objections of the written statement is relevant for the purpose of disposal of the present complaint and is reproduced as under:-
That the complainant obtained a Happy Family Floater Policy for the period 12.6.2011 to 11.6.2012 vide policy no. 271601/48/2012/1015 for the sum insured of Rs. 6,00,000/-. During the continuation of the above mentioned policy, the claim was lodged on account of the hospitalization by the complainant the hospital for the period 12.2.2012 to 25.2.2012 on account of non specific chronic jejunitis, hypertension, lumbar sypondylosis, leukocytosis. After receiving the claim intimation , the opposite party no. 1 appointed OP no. 2 M/s Vipul Med Corp TPA Pvt. Ltd to investigate and assess the claim of the complainant. The opposite party no. 2 was asked to issue pre-authorization of cashless facility for the treatment of the complainant. The opposite party no. 2 was asked to issue pre-authorization of cashless facility for the treatment of the complainant in Sir Ganga Ram Hospital but as per the opinion of the opposite party no.2 , the complainant was not entitled for the pre-authorization for the reason that the previous coverage from the National Insurance Company was not be considered , hence, the policy obtained by the complainant with opposite party no.1 is to be treated as first year policy w.e.f. 12.6.2011 , the claim of the complainant was not admissible under exclusion of the policy. The facts about the non entitlement of the pre-authorization of the cashless facility was intimated to the aforesaid hospital by the OP2 vide its letter dated 14.2.2012. The matter was investigated by the OP2 and the OP2 came to the conclusion that the claim of the complainant is not admissible under clause 4.3. (xvi) of the Medi Claim Policy. The policy obtained by the complainant with the OP no. 1 was the first running policy w.e.f. 12.6.2011 as the complainant was earlier covered with National Insurance Co. Ltd which is not considered as per clause no. 4.3 of the terms and conditons of the insurance policy issued by the OP no. 1. If the continuity of the renewal of the insurance policy is not maintained with the insurance company, then the subsequent insurance cover shall be treated as a fresh policy. The OP no. 2 also came to the conclusion that as per the Migration clause no. 6 of the Happy Family Floater Policy issued by the OP no. 1, the migration is not allowed from other insurer. As per the opinion of the OP no. 2, the clause 4.3 (xvi) of the terms and conditons of the insurance policy issued by the OP no. 1 excludes Gout and Rheumatism of any kind for a period of 2 years. Hence, as per the opinion of OP no. 2, the claim of the complainant was not admissible as per the terms and conditions of the insurance policy and the same was intimated by the OP. 2 to OP1 vide its letter dated 17.3.2012. After receiving the opinion of th OP 2 the competent authority of OP no1 came to the conclusion that the claim of the complainat is not maintainable and the same was intimated to the complainant by OP1 vide its letter dated 1.5.2012. In the said letter the complainant was informed that he was having a history of non-specific chronic jejunitis hypertension, lumber spondylitis, leukocytosis and the same was excluded as per clause 4.3 of the terms and conditions of the insurance policy. As the claim of the complaiant was not payable as per the terms and conditions of the insurance policy and the same was accordingly intimated to the claimant, he is not entitled to file the present claim/ complaint before this Hon’ble Forum.
OP1 has contested the complaint on merits and has prayed for its dismissal.
We have heard arguments advanced at the bar and have perused the record. The sole question for our determination is as to whether OP1 was justified in repudiating the claim lodged by the complainant. OP1 has claimd tha the claim was not payable as per exclusion clause 4.3 of the policy of insurance purchased by the complainant. The relevant portion of clause 4.3 of the insurance policy is reproduced as under:-
4.3 The expenses on treatment of following ailments/ diseases/ surgeries for the specified periods are not payable if contracted and / or manifested during the currency of the policy:
If these diseases are pre-existing at the time of proposal the exclusion no. 4.1 for pre-existing condition shall be applicable in such cases:
XXXXX XXXXX XXXXX
XXXXX XXXXX XXXXX
XXXXX XXXXX XXXXX
XXXXX XXXXX XXXXX
(xvi) Gout and Rhenumatism 2 Years
(xvii) Hypertension 2 Years
XXXXX XXXXX XXXXX
XXXXX XXXXX XXXXX
The learned counsel for the OP has forcefully contended that the complainant had purchased the policy from it for the first time on 12.6.2011 and, therefore, it has to be treated as a fresh h policy. He has contended that the OP was , therefore, justified in repudiating the claim under clause 4.3 ibid.
The learned counsel for the complainant on the other hand has contended that the OP1 has failed to give the benefit of Health Insurance Portability. As per IRDA guidelines.
We have considered the contentions on both sides. Insurance Regulatory and Development Authority has issued guidelines on 9-9-2011 under the head portability it reads:-
- Portability : Portability means the right accorded to an individual health insurance policy holder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.
- Break in policy: A break in policy occurs when the premium due on a given policy is not paid on or before the premium renewal date or within 30 days thereof.
A bare perusal of the aforesaid guidelines issued by IRDA makes it amply clear that the policy purchased by the complainant from OP1 in the year 2011 could not have been taken as a fresh policy. As per the above guidelines the complainant was entitled to transfer the credit gained by him for pre-existing conditions and time bound exclusions provided the previous policies had been maintained without any break. It is not the case of OP1 that there was a break in the earlier policies purchased by the complainant. We are, therefore, of the considered opinion that exclusion clause 4.3 ibid could not have applied to repudiate the claim lodged by the complainant. In the result we hold that the OP was deficient in rendering services by the complainant. We direct it as under:-
- Pay a sum of Rs. 3, 01596/- ( Rs Three Lakhs One Thousand Five Hundred and Ninety Six Only) along with interest @ 10% p.a. from the date of filing of this complaint i.e. 14.12.2013 till payment.
- Pay a sum of Rs. 25,000/- to the complainant as compensation for pain and agony suffered by him.
- Pay a sum of Rs. 5,000/- as cost of litigation.
OP1 shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. IF the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule. File be consigned to record room.
Announced in open sitting of the Forum on.....................
