SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)
The Complainant has filed this complaint petition, U/s-35 of C.P.Act-2019, (here-in- after called as the “Act”), on dated 13.01.2021, alleging a “deficiency-in-service” by the OP, where OP is the Religare Health Insurance Company. That, as per the complainant’s petition the cause of action arose on 2.12.2020, 23.12.2020 and 24.12.2020.
In the present case, the OP appeared after being receipt of notice issued against him and filed his written version.
The case of the complainant, in a nutshell, is that on 22.02.2020 complainant being insisted by one Sucheta Rakshit, the intermediary of the OP-insurer, has purchased the Care Floater Insurance policy for a sum assured of Rs.5,00,000.00 bearing Policy No.16933429, who issued with a policy certificate and cashless Health Insurance Card bearing IRDA Registration No.148 by paying premium amount of Rs. 52,258/-. The said policy was valid from 22.2.2020 to 21.2.2022. It is the specific case of the complainant that on 25.11.2020, he was suddenly attacked with a cardiac problem and got admitted in CTVS-ICU Ward in Bed No.1004 of AMRI Hospital, Bhubaneswar on 01.12.2020. The said hospital authority asked the complainant for deposit of Rs.10,350.00 for his initial check-up. Thus, the complainant handed over the cashless Health Insurance Card issued to him by the OP to the hospital authority for debit of the amount, but the same was turned down for which the complainant paid the amount in cash. There at AMRI Hospital, the coronary angio was done through percutaneous femoral/radial route right by selective annulation of L and R coronary arteries followed by L.V. angiography. On 02.12.2020, the OP vide Al. No.80453323-00 sent a deficiency letter to the Hospital concerned requesting to provide CATH LAB NOTE in respect of four items for enabling the OP to review preauthorization to use cashless insurance card. The complainant was complied with the information/documents as sought for by the OP. But on the same day, the OP sent one “Denial” letter to the AMRI Hospital declining preauthorization for the complainant on the ground of four years waiting period for treatment of pre-existing disease and its complications. It is further stated that the ailments of the complainant was not a pre-existing one, rather it was a sudden outburst. The complainant with much difficulty and stress could manage to pay the expenses for hospitalization i.e. Rs.1,95,058.00 and on 2.12.2020, the complainant discharged from the hospital.
It is alleged by the complainant further that his Health Insurance covered the benefit of Day Care Surgeries i.e. Coronary Angiography which is covered the benefit, as mentioned in Page-44 of the policy brochure. The OP has played an unfair practice and the service agreed to be extended by the OP to the complainant at the time of Care Health Insurance is deficient which hazardous to the life and safety of the complainant. The OP has also contravened the standard norms of the policy by denying the preauthorization of hospitalization.
It is further alleged by the complainant that after his discharge from the hospital, he sent his grievance to the OP so also to its Registered Office at New Delhi on 21.12.2020 which were received by them on 23.12.2020 and 24.12.2020 respectively, but in vain. Therefore, the complainant, finding no other way out, was constrained to file the complaint alleging about deficiency in service and unfair trade practice on the part of the OP. Hence, this case.
To substantiate his case, the complainant relied upon the following documents, which are placed in the record-
- Photocopy of policy certificate.
- Photocopy of cashless Health Insurance Card bearing IRDA No.149.
- Photocopy of initial diagnosis report dated 1.12.2020.
- Photocopy of coronary angiography report.
- Photocopy of stenting document.
- Photocopy of deficiency letter issued by OP.
- Photocopy of denial letter issued by OP.
- Photocopy of discharge summary report.
- Photocopy of payment receipts.
- Copy of grievance petition with postal receipts.
- Tracking consignment reports.
The OP in his written version, challenging the averments made in the complaint petition, has stated that the complainant has no cause of action to file the present case and the case is not maintainable. Further, it has been stated that this Commission has no jurisdiction to sit over the matter. It is the specific case of the OP that the complainant had purchased the Care Floater Insurance policy for a sum assured of Rs.5,00,000.00 bearing Policy No.16933429 on submission of proposal on line for himself and for his family members for reimbursement of pre & post hospitalization expenses along with other charges. On 1.12.2020, the OP-company received a Pre-authorization Form-Care, AMRI Hospital, Bhubaneswar for issuance of cashless facility for hospitalization/treatment of the complainant-insured who was admitted on the same day along with some medical documents wherein it has been mentioned that the complainant has been admitted in their hospital with complain of chest pain with short breathing and provisional diagnosed with Ischaemic Heart Disease and the complainant is stated to have gone for surgery of angio plasty. On perusal of the request and medical documents, the OP-company observed that the complainant has history of DM and HTN for which raised some query to the AMRI hospital. On perusal of the answer to the query and the prescription and progress note, OP-company found that the duration and past ailment history of the complainant was since 2015 and the medical paper reveals that the complainant was suffering Hypertension, Type 2 Diabetic Miletus prior to purchase of Care Floater Insurance Policy hence he is suffering from Ischaemic Heart Disease. In the instant case, the complainant has obtained the Policy just before 9 months 10 days of his hospitalization for which the OP-company did not approve or issue pre-authorization of cashless service facility to AMRI hospital for hospitalization of the complainant and the said fact was intimated to AMRI hospital on 2.12.2020. Thus, there is no question of deficiency of service on the part of OP-company.
It is the further case of the OP that when the complainant had occasion to disclose to history of Type 2 DM and HTN since 2015 i.e. prior to inception of the policy in question at the time of proposal, but the complainant did not disclose the said pre-existing disease deliberately and intentionally and also supplied negative answer that he or his family member had no pre-existing diseases and thereby suppressed the material facts to which the OP-company had no knowledge. On the other hand, the OP-company is prejudiced for suppression or concealment of the material information which are to be supplied by the complainant at the time of proposal form for Care Floater Insurance Policy. The complainant had obtained the policy in question maliciously by practicing fraud and misrepresentation and that concealment of any material facts entitles the OP-company to repudiate the claim and thus, no benefit can be drawn by the complainant. In para 9 of their submission the Op-company submitted that the complainant has only asked for pre-authorization of cash less facility against his hospitalization but has not filed/lodged any claim for reimbursement of the expenditure incurred by the complainant during hospitalization from 1.2.2020 to 2.12.202. Hence, the OP-company prayed to dismiss the complaint with cost.
In order to substantiate its case, the OP relied upon the following documents, which are placed in the record-
- Photocopy of proposal form submitted by the complainant.
- Photocopy of care floater policy-cum-policy certificate with term and conditions.
- Photocopy of premium acknowledgement.
- Photocopy of pre-authorization form submitted by AMRI hospital.
- Photocopy of letter dated 2.12.2020 issued by OP-company to AMRI hospital.
- Photocopy of reply of AMRI hospital dated 2.12.2020.
- Photocopy of photo copy of prescription dated 22.11.2020.
- Photocopy of photo copy history & physical record of AMRI hospital.
- Photocopy of photo copy of progress note dated 1.12.2020 of AMRI hospital.
- Photocopy of inpatient bills of AMRI hospital dated 2.12.2020.
- Photocopy of discharge summary of AMRI hospital.
- Photocopy of denial letter dated 2.12.2020 of OP-company to AMRI hospital.
In view of the above averments of both the parties, the points for determination in this case are as follows:-
- Whether the complainant is a consumer as per C.P Act, 2019?
- Whether there is any cause of action to file this case?
- Whether the present case is maintainable?
- Whether there is any deficiency of service on the part of the OP towards the complainant?
- To what other relief(s), the complainant is entitled to?
F I N D I N G S
So far as the issue as to whether the complainant is a consumer or not is concerned, first of all, it is to be seen how far the complainant is proved himself to be a consumer under the Ops. The complainant has purchased the Care Floater Insurance policy from the Op for a sum assured of Rs.5,00,000.00 bearing Policy No.16933429, with cashless facility by paying premium amount of Rs.52,258/-, so he is a consumer.
As regards the cause of action, it is alleged by the complainant that the denial of pre-authorization on dt. 2.12.2020 and non-reply of his grievance by the OP which were received by them on 23.12.2020 and 24.12.2020 respectively are the cause of action to file this case. It is the stand of the complainant that he has incurred expenditure amounting to Rs.1,95,058.00 in total (as per Annexure-9 series) for his hospitalization and treatment and when the OP played unfair practice and the service which were to be provided did not provide, for which after his discharge from the hospital, the complainant presented his grievance (as per Annexure-10) before the OP which was received by the OP on 23.12.2020, but in vain. From the above, it is clearly made out that the complainant has cause of action to file the case.
In order to arrive at a definite conclusion, it is required to be decided as to whether the case is maintainable and whether there is any deficiency of service on the part of the OP towards the complainant. It is admitted that the complainant has purchased the policy in question for a sum assured of Rs.5,00,000.00 under the plan Care Health Insurance of OP and the policy was valid from 22.2.2020 to 21.2.2022. It is also an admitted fact that the complainant had admitted in AMRI hospital for his sudden cardiac problem on 25.11.2020 and informed the OP for cashless facilities. On 2.12.2020, the OP called for additional information with regard to complete indoor case papers with admission notes, history sheet, doctor’s notes, exact duration and past history of present ailment along with first consultation paper and others. On the same day, the hospital authority had submitted all the informations as required by the OP for pre-authorization of cashless hospitalization, but the OP blatantly denied for pre-authorization cashless facility on the ground of four years waiting period for treatment of pre-existing disease and its complications for which the complainant paid the hospitalization expenses @ Rs.1,95,058.00 in cash.
On the other hand, it is the stand of the OP that on receipt of the request of AMRI hospital for issuance of pre-authorization cashless facility for hospitalization of the complainant in their hospital who was admitted on 1.12.2020 along with medical documents in which it was mentioned that the complainant was admitted in AMRI hospital with chest pain with short breathing Class-II with Ischemic Heart Disease and it stated to have gone for surgery of Angio Plasty. Upon perusal of the documents along with pre-authorization form, it was observed that the complainant has history of DM and HTN for which raised query to AMRI hospital seeking the informations as stated earlier. Thereafter, the authority of AMRI hospital sent back the query letter dated 2.12.2020 along with prescription dated 22.12.2020 of treating physician, history record and progress note of the complainant wherefrom it was made out that the complainant has stated to be known case of IHD, Type 2 DM and HTN on medication and suggested for diabetic diet and the progress note in the name of the complainant dated 1.12.2020 revealed that the complainant is marked with known case of IHD, HTN and Type 2 DM. Therefore, the complainant was suffering from HTN, Type 2 DM and IHD prior to purchase of Insurance policy from the OP. That apart, pre-existing disease means any condition ailment or injury or related condition for which the complainant had signs or symptoms and was diagnosed or received medical treatment within 48 months prior to the first policy issued by the OP and the waiting period of coverage of any medical expenses incurred for hospitalization in respect of any pre-existing disease under issued policy is 48 months of continuous coverage has lapsed since inception of the first policy. In the present case, the complainant has purchased the policy in question just before 9 months and 10 days of his hospitalization. So, the OP did not approve pre-authorization of cashless service facility to AMRI hospital for treatment of Ischemic Heart Disease, UA and the said fact was intimated to AMRI hospital. Therefore, no question regarding deficiency of service on the part of OP does not arise.
From the above discussions, it is found that the complainant had purchased Care Health Insurance policy from the OP for a sum of Rs.5,00,000.00 on 22.02.2020 which was valid till the midnight of 21.02.2022. On 25.11.2020 the complainant was suddenly attacked with cardiac problem and was admitted in AMRI hospital on 1.12.2020. The complainant made over his cashless insurance card issued to him to the hospital authority. The hospital authority sent intimation to the OP for cashless facility. Thereafter, the OP made some query and information regarding complete indoor case papers with admission notes, history sheet, doctor’s notes, exact duration and past history of present ailment along with first consultation paper and others to which AMRI hospital sent all the required informations and documents to the OP. After examination of the informations and documents submitted by AMRI hospital, where the complainant was hospitalized, the OP did not approve pre-authorization of cashless service facility to AMRI hospital for treatment of Ischemic Heart Disease, UA and the said fact was intimated to AMRI hospital on the ground that the complainant was suffering from known Type 2 DM and HTN on radiation, as such the course of treatment which showed CAD-SVD owing to this PTCA to OM as taken by the complainant for treatment of IHD is pre-existing disease, because HTN is the causative factor of the disease IHD. Further, the waiting period of admissibility or coverage of any medical expenses incurred for hospitalization in respect of any pre-existing disease under the police in question is 48 months of continuous coverage has lapsed since inception of the first policy with the OP, but in the present case, the complainant has obtained the policy in question just before 9 months and 10 days of his treatment in AMRI hospital. Thus, the OP did not approve pre-authorization of cashless service facility to AMRI hospital.
That apart, the complainant did not disclose the said pre-existing disease or ailments intentionally prior to inception of the policy in question at the time of proposal. The complainant had supplied wrong and false informations with regards to the Additional details in proposal Form –“CARE” in Col-A knowing very well that these were false and incorrect. Thus, the complainant has intentionally and fraudulently concealed the true state of affairs regarding his health at the time of proposal for insurance on 21.2.2020. It is, therefore, held that the ailments from which the complainant was suffering is prior to the date of proposal for which the OP did not accept the risk on the health of the complainant. Had the complainant disclosed the true facts and informations at the time of proposal for insurance, the risk under the policy in question would not have been accepted by the OP and the policy in question would not have been issued to complainant or would have been issued on different terms and conditions. In all the contract of insurance, the proposer is bound to make full disclosureof all the material facts and nor merely those, which he thinks material, misrepresentation, non-disclosure or fraud in any document leading to acceptance of the risk automatically discharges the insurer from all liabilities under the contract. On the other hand, the complainant had also supplied a false declaration that the informations supplied by him are all true, accurate and complete and correct in all respects. Hence, it is observed that the contract of insurance is null and void.
From the above discussions, it is held that there is no deficiency of service on the part of the OP in providing cashless facility from Care Health Insurance and the complaint of the complainant is not maintainable. Therefore, the complainant is not entitled to any other reliefs as sought for.
Hence, it is ordered: –
O R D E R
The complaint of the complainant is hereby dismissed on contest against the OP. In the facts and circumstances, no order as to cost.
Pronounced in the open Court of this Commission on this day i.e. the 23rd day of May, 2023 given under my Signature & Seal of the commission.
