This complaint case is filed by one Sri Jagannath Paul and Sri Nilabjo Paul against Branch Manager, Oriental Insurance Co. Ltd. and Manager, Vipul Medcorp TPA Pvt. Ltd., praying for a direction upon the OPs to pay the Complainants a sum of Rs. 36,106/- in full and final settlement of their claim and compensation for a sum of Rs. 50,000/- and litigation cost to the tune of Rs. 10,000/-.

In a brief compass, case of the Complainants, is that, they took a mediclaim policy from the OPs for the first time on 11-07-2003 which covered the Complainant No. 1, his wife and the Complainant No. 2 (only son of the Complainant No. 1) individually to the tune specified in the said policy.  Subsequently, w.e.f. 11-07-2012, they migrated to Happy Family Floater Policy.  On 23-05-2015, the Complainant No. 1 suddenly felt chest pain with sweating and thereafter, he was admitted at Woodlands Multispecialty Hospital and was discharged on 26-05-2015 with final diagnosis, “Congenital Cyanotic Heart Disease Tetralogy of Fallot Pulmonary Arterial Hypertension.”  At the said hospital, Complainant had to incur Rs. 35,131/- which was duly paid by the Complainant No. 2.  On 29-05-2015, Complainant No. 2 submitted claim form before the OP No. 2 as per instruction of the OP No. 1 for reimbursement of the medical expenses amounting to Rs. 36,106/-.  OP No. 1, by its letter dated 19-06-2015, repudiated the claim on some baseless, imaginary, and flimsy grounds.  Complainant No. 1, thereafter, sent a letter to the OP No. 1 on 30-06-2015 stating that he was unaware of such congenital disease since his childhood and he became aware of it for the first time when he was admitted on 23-05-2015 at Woodlands Hospital and pleaded before the OP No. 1 to reconsider the claim.  However, the OP No. 1, by its letter dated 21-07-2015, finally repudiated the claim of the Complainants.  Hence, this case.

OP No. 1 contested the case by submitting a WV, whereby it disputed all the material allegations of the complaint.  It is further stated that the ground for repudiation of the claim was clarified in simple terms leaving no room for any ambiguity.  The claim of the Complainants is barred under Exclusion Clause 4.8 of the policy issued to him and as such, there was no infirmity over repudiation of such claim.  Accordingly, it prayed for dismissal of the case.

We are to decide, whether or not, the Complainants are entitled to the reliefs prayed for by them.

Decision with reasons

It appears from the repudiation letter of the OP No. 1 dated 21-07-2015 that insofar as the disease of the Complainant No. 1 falls under Exclusion Clause No. 4.8 of the Happy Family Floater Policy, such claim was not admissible and accordingly, it treated the claim as “No Claim”.

On going through the Discharge Summary of Woodlands Hospital dated 26-05-2015, it transpires that final diagnosis was made by the treating doctor as, “Congenital Cyanotic Heart Disease Tetralogy of Fallot Pulmonary Arterial Hypertension”. 

According to the OP no. 1 insofar as “congenital external and internal diseases or defects or anomalies” falls under Exclusion Clause No. 4.8 of the Policy in question, it rightly repudiated the claim. Per contra, it is argued from the side of the Complainants that they were not aware of such disease beforehand and never underwent treatment for such disease prior to admission at the Woodlands Hospital on 23-05-2015.  Further case of the Complainants is that they were not shown the detail features of the “Happy Family Floater Policy”, but merely handed over a brochure containing some of the salient features of the said policy and nowhere in the said brochure there was any mention of the fact that congenital diseases have been kept outside the purview of the said policy altogether and they were not asked to sign any proposal form for this purpose. 

Against this backdrop, let us see, whether the OPs rightly repudiated the claim or not.

According to Oxford dictionary, the term “congenital” means, “(Of a disease or physical abnormality) present from birth”.  The Merriam Webster describes “congenital” as “existing at or dating from birth”.  The Cambridge Dictionary defines “congenital” as a “disease or condition exists at or from birth”.

          So, going by literal meaning of the word “congenital”, it is of paramount importance to determine whether the person is/was suffering from such disease/ailment since birth or not.  On going through the discharge summery on record, we find that, it is clearly mentioned therein that the patient/Complainant No. 1 had no significant past medical/surgical/family history of such ailment.  Against such backdrop, on what basis the treating doctor derived at such conclusion, remains unexplained.  It is highly unlikely that the patient would not candidly report past history of his ailment to the attending physician. 

          Significantly, not a single piece of past treatment sheet is placed before us to show that the Complainant ever underwent treatment for such ailment.  In fact, it is the admitted position of this case that the Complainant No. 1 never staked any insurance claim since coming under the shelter of mediclaim policy, way back in the year 2003.

          Further, on going through the specimen copy of policy document in respect of “Mediclaim Insurance Policy (Individuals)”, which was initially taken by the Complainant, it appears that in respect of that policy congenital internal diseases have a cooling off period of two years since inception. However, under the Happy Family Floater Policy, this kind of disease has been completely taken off the radar. 

          Now the question remains, whether the Complainant was at all aware of such implications prior to migrating from Mediclaim Insurance Policy (Individuals) to Happy Family Floater Policy.  It is stated by the Complainants that they did not fill up any proposal form for this purpose.  In fact, OP No. 1 has also not placed on record copy of any proposal form to refute such claim.  There can be no two opinions as to the fact that keeping a prospective policyholder above board about vital features of the concerned insurance policy is the utmost responsibility of the Insurer, which it cannot take lightly.  A higher degree of accountability is expected from the Insurer so as to ensure that the incumbent policyholder can properly weigh the pros and cons of the policy concerned in order to come to a judicious decision about whether or not to opt for the same.

Here, we find, Complainant was only provided a Prospectus in respect of Happy Family Floater Policy, containing some of the attractive features of the said policy.  On going through the same, we do not find any whisper about exclusion clause in respect of congenital diseases.  Thus, it seems to us that the Complainant was not properly taken into confidence by the authorized agent of OP No. 1 about the fine prints of this policy which clearly brings to fore element of unfair trade practice on the part of the men/agent of OP No. 1.  As we know, the principal is vicariously liable for the acts/conduct of its agent.  Therefore, the OP No. 1 cannot avoid its responsibility for not properly educating the Complainants about the contents of exclusion clause as embedded in the policy document of Happy Family Floater Policy.  

Keeping in mind all such facts into perspective, we are of view that by repudiating the claim of the Complainants, OPs have not acted in the true spirit of the insurance policy.  Rejecting a claim by hook or by crook cannot be the be all and end all of any insurance company.  Rather, it seems, by working tirelessly to uphold larger social cause, an Insurer would do yeoman service to the society at large.

We have to keep in mind that one is subjected to intense medical check-ups at the time of opting for an insurance policy.  Given the fact that the Complainant No. 1 was duly checked by the panel doctor of the OP Insurer and a simple ECG is suffice to detect heart related disorders, when the panel doctor of the OP Insurer given a clean chit to the Complainant No. 1, at this stage, we see no reason whatsoever to endorse the decision of the OP Insurer to repudiate the claim of the Complainants.  Accordingly, we deem it fit and proper to direct the OPs settle the claim of the Complainants in full.

Hence,

O R D E R E D

that CC/69/2015 be and the same is allowed on contest against the OP No. 1 and ex parte against the OP No. 2.  OPs are directed to pay Rs. 36,106/- to the Complainant No. 1 together with compensation and litigation cost for a sum of Rs. 10,000/- and Rs. 2,000/-, respectively, within two months hence, subject to submission of all the treatment bills in original, if not already submitted, i.d., the amount shall carry interest @ 10% p.a. from the date of this order.