1. The brief facts of the case of the complainant are that he is a member of Good Health TPA Services Ltd., enrolled under Andhra Bank (OP.1) Arogyadaan group health insurance policy No.0504002815P103075013 for which the OP.2 is the insurer for the policy period 09.6.2015 to 08.6.2016 whereas the complainant obtained the policy on 30.10.2015 vide GHPL ID No.GHUIABO1888824 for a sum assured of Rs.2.00 lakhs. It is submitted that the complainant felt mild chest pain during policy period and contacted Apollo Hospital, Visakhapatnam on 01.12.2015 who diagnosed Coronary Artery Disease. As the complainant wanted to undergo surgery at Sir Gangaram Hospital at New Delhi for his convenience, he was discharged from the said hospital on 02.12.2015. It is further submitted that on 09.12.2015 the complainant was admitted to Sir Gangaram Hospital at New Delhi for Coronary Artery Bypass Surgery and was discharged on 18.12.2015 incurring an expenditure of Rs.1, 26,855/- and has sent all documents along with bills for reimbursement who received the bills and documents vide Claim No.142467 and the complainant has sent additional documents as required by OP.3 to which the OP has also received on 13.2.2016. It is also submitted that the OP.3 repudiated the claim on 31.3.2016 citing the reason that “As per submitted discharge summery patient has complaint of chest pain on exertion since past 6 months. Hence the condition is pre-existing as per policy terms and conditions vide Clause-6.1, the claim is not payable”. The complainant submitted that the Apollo Hospital in its report says that the symptom is 3 months old whereas the Sir Gangaram Hospital in its discharge summery says that the history of chest pain on exertion for last 6 months and both the reports are contradictory to each other and the complainant has never admitted or consulted any doctor for chest pain in the past. Thus alleging unfair trade practice on the part of the Ops, he filed this case praying the Forum to direct the Ops to pay Rs.1, 26, 855/- towards claim amount with interest @ 18% p.a. from 18.12.2015 and to pay Rs.1.00 lakh towards compensation and costs to the complainant.
2. The OP.1 filed counter denying the allegations of the complainant and contended that the complainant being the member of Good Health TPA Services Ltd. (OP.3) has obtained the mediclaim insurance policy under OP.2 and the complainant has deposited his premium with OP.1 which has been duly credited to the accounts of OP.2 by OP.1. It is contended that any liability arises to pay the insured person, it is the liability of Ops 2 & 3 and the OP.1 is not responsible for any claim. Thus denying any fault on its part, the OP.1 prayed to dismiss the case of the complainant.
3. The OP No.2 also filed counter contending that on receipt of intimation from the complainant, the TPA Ltd. have issued authorization letter to Sir Gangaram Hospital stating certain terms and conditions and the said hospital categorically stated that the complainant presented with a history of chest pain on exertion for last 6 months. It is further contended that Dr. B. Ravi Kishore, Chief Medical Officer, TPA Service Ltd. vide his letter dt.20.10.2016 has categorically specified the details after perusing all documents and opined denying the liability to pay the claim. It is also further contended that after going through all the documents, terms and conditions of insurance policy and other documentary evidence, the claim of the complainant has been repudiated. Thus denying any fault on its part, the OP prayed to dismiss the case of the complainant. The OP No.3 in spite of valid notice did not prefer to participate in this case in any manner.
4. The complainant as well as OP.2 has filed certain documents in support of their cases. The OP.2 has filed affidavit. Heard from the complainant and A/R for contesting Ops and also perused the materials available on record.
5. In this case, it is an admitted fact that the complainant is a member of Good Health TPA Services Ltd., through Andhra Bank Arogyadaan group health insurance policy No. 0504002815P103075013 for which the OP.2 is the insurer for the period 09.6.2015 to 08.6.2016 and the date of inception of policy is 30.10.2015 on due payment vide GHPL ID No. GHUIABO1888824 for a sum assured of Rs.2.00 lakhs. The OP.1 also admitted that the OP.2 is having its central premium collection account at Hyderabad with the Head Office of OP.1 and the premium of the complainant has been credited to the accounts of the OP.2, the insurer and they have nothing to do in the settlement of claim in favour of the complainant.
6. It is the case of the complainant that while the policy was in force, he felt mild chest pain and admitted at Apollo hospital, VSP on 01.12.2015 which diagnosed Coronary artery disease after Angiogram test. The treating doctor advised for CABG but the complainant preferred to undergo surgery at Sir Gangaram Hospital, New Delhi and hence he was discharged from the said hospital on 02.12.2015. Further he was admitted at Sir Gangaram hospital on 09.12.2015 for surgery which was done on 11.12.2015 and the complainant discharged on 18.12.2015 incurring an expenditure of Rs.1, 26,855/-. It is the further case of the complainant that he submitted all necessary bills and vouchers with OP.3 on 11.1.2016 vide Claim No.142467 and further documents on 13.2.2016 on call but the OP.3 on 31.3.2016 repudiated the claim stating that the chest pain of the complainant on exertion since past 6 months and as per policy condition, the claim is not payable. According to the complainant, the Apollo hospital says that the disease is of 3 months old whereas Sir Gangaram hospital says that the disease is of 6 months but he has neither felt such complaint previously nor consulted any doctor for the disease in question in the past and hence the repudiation of claim by Ops is illegal.
7. The learned A/R for the OP.2 submitted that the TPA Services Ltd. has issued an authorization letter to Sir Gangaram hospital stating certain terms and conditions and Dr. B. Ravi Kishore, CMO of said hospital vide his letter dt.20.10.2016 has categorically opined that as per discharge summery, the patient has complaint of chest pain due to exertion since 6 months and the present hospitalization is for pre-existing disease and hence the claim was denied for the above reasons. The argument was based on the hospital discharge summery.
8. We have carefully gone through the discharge summery of both the hospitals as mentioned above. The complainant was admitted in the Apollo hospital on 01.12.2015 and diagnosed Coronary Artery disease, AOE Class II & III which is 3 months old and the recommendation was CABG. As the complainant did not agree to undergo surgery at the said hospital, the patient was discharged on 02.12.2015 against medical advice.
9. Further the complainant was admitted in the Sir Gangaram hospital on 09.12.2015 and operation was done on 11.12.2015. The complainant was discharged from the hospital on 18.12.2015. It is seen that the treating doctor in the discharge summery stated that the chest pain on exertion was for last 6 months. On going through the discharge summery of the hospital that the chest pain was pre-existing, Ops have repudiated the claim.
10. It is the further case of the complainant that he had neither felt any chest pain prior to admission in the hospital at VSP nor consulted any doctor about chest pain in the past. It is seen that the Ops have not challenged the said averment of the complainant by adducing any evidence. It is a settled principle of law that insurance cover is subject to terms and conditions of the policy but while denying the liability by an insurer, it has to be adduced sufficient evidence which would throw light to the issues under controversy.
11. Of course the discharge certificate of both the hospitals at VSP and New Delhi reveal that the complicacy was pre-existing since last 3 and 6 months respectively but the Ops failed to prove that the complainant was having history of any heart disease or was admitted at any hospital or was consulted any doctor prior to taking the policy in question. Mere history given in hospital ipso facto was of no consequence as it alone cannot be treated as valid ground to repudiate the claim and that in case of pre-existing disease, the onus heavily lies on the insurer to prove the pre-existing disease by adducing cogent evidence where the complainant has received treatment earlier to the hospitalization in the above two hospitals in the face of specific stand of the complainant that he had neither consulted any doctor nor admitted at any hospital for coronary artery disease prior to the inception of the policy.
12. In the above circumstances, we do not accept the stand taken by the Ops 2 & 3 while repudiating the claim of the complainant and therefore we safely hold that the disease for which the complainant had undergone surgery was not pre-existing in absence of clear and specific evidence from the side of the Ops. In that line we also further hold that the complainant had no knowledge or symptom of that disease while proposing the policy with the Ops. As such the repudiation of the claim by the Ops 2 & 3 is illegal and as such the repudiation could not be accepted by us in the above circumstances. Therefore, the complainant is entitled for claim of Rs.1, 26,855/- which he has incurred at Sir Gangaram hospital with interest @ 12% p.a. from the date of repudiation i.e. 25.5.2016. In the peculiar circumstance of the case, we are not inclined to award any compensation in favour of the complainant as prayed for except a sum of Rs.3000/- towards costs.
13. Hence ordered that the complaint petition is allowed in part and the OP No.2 and 3 being jointly and severally liable are directed to settle the claim at Rs.1, 26,855/- with interest @ 12% p.a. from 25.5.2016 and to pay Rs.3000/- towards costs to the complainant within 30 days from the date of communication of this order.
(to dict.)
