By Smt. Bindu. R, President:
This complaint is filed by Omana Elias, W/o. Varghese, Aged 58 years, Kannamparambil House, Sulthan Bathery Post, Kuppadi Village, Sulthan Bathery Taluk, Wayanad, Pin 673 592 against the Branch Manager, Star Health and Allied Insurance Co. Ltd., Aftab Building, Sulthan Bathery Post, Village, Sulthan Bathery Taluk, Wayand, Pin 673 592 as Opposite Party alleging deficiency of service and unfair trade practice from their side.
2. The Complainant states that the Complainant is the beneficiary of Medi Classic Insurance Policy (individual) issued by Opposite Party as per policy No.P/181315/01/2020/001394 having period from 11.07.2019 to 10.07.2020. According to the Complainant the Opposite Party had offered either cashless treatment or entire reimbursement of hospital expenses to the Complainant and it is also told that one day admission in the hospital is the eligibility for claim amount. The Complainant states that the Complainant had felt suffocation and chest pain and was taken to Vinayaka Hospital, Sulthan bathery initially and due to recurrent chest pain, she was then transferred to Leo Metro Cardiac Centre, Kalpetta on 03.05.2020. The Complainant was treated as inpatient No.18884 and she was taken up for a coronary angiogram via right radial artery approach on 03.05.2020. Subsequently she underwent PTCA to major OM2 with 1 DES via right femoral artery approach. The Complainant was further treated with Inj.Fondaflo, antiplatelets, statins along with other symptomatic and supportive measures and discharged on 06.05.2020. The Complainant had intimated the claim to Opposite Party immediately after the admission, and they registered the claim as claim intimation No.0030714, and told that they could not process the file for cashless scheme due to lock down and offered the reimbursement. The original of all documents including treatment records and medical bills are obtained by the Opposite Party on 16.05.2010 (as written in the complaint) and the Opposite Party offered to settle the bill. But the claim was repudiated on 03.05.2020. Since the Opposite Party had not provided cashless treatment, the Complainant was compelled to pay Rs.1,40,814/- as the hospital bill to Leo Metro Cardiac Centre, Kalpetta. The Complainant states that even though the Opposite Party assured 100% reimbursement of hospital expenses, the Opposite Party had repudiated the claim instead of issuing a cheque for the claim amount. The reason stated in the repudiation letter is that the Complainant is not eligible for claim because the Complainant has been suffering from SQUAMOUS CELL CARCINOMA and had failed to disclose the pre existing disease. The Complainant states that the policy was canvassed by her close friend who was aware of the treatment in 2017 and the same was told to the agent and the personnel who accompanied the agent at the time of taking the policy. According to the Complainant the pre existing disease is related to pimple and is disclosed to the agent. The Complainant states that the Opposite Party canvassed the policy by offering cashless treatments and easy processes and hence the repudiation of claim amounts to unfair trade practice from the side of the Opposite Party and hence the complaint praying to issue direction to the Opposite Party to pay an amount of Rs.1,40,814/- as hospital expenses with 18% interest along with other reliefs.
3. Upon notice the Opposite Party entered into appearance and filed their version contending that the complaint is not maintainable either in law or on facts. The complaint is without any bonafides and with ulterior motive for making illegal gains. The Opposite Party contented that the Complainant took a medi classic individual policy for a period commencing from 11.07.2019 to 10.07.2020 for a sum insured of Rs.2,00,000/- and at the time of issuing the policy the Complainant was supplied with the terms and conditions of the policy and the same was explained to the Complainant at the time of proposing the policy. More over it is clearly stated in the policy schedule that “The insurance under this policy is subject to condition, clauses, warranties, exclusions etc attached”. According to the Opposite Party, the policy is issued based on the proposal form submitted and the Complainant had not revealed anything about the pre existing diseases in the proposal form except that she had undergone uterus removal in 2014. It is admitted by the Opposite Party in their written version that since the Complainant is above 50 years of age a pre medical examination was conducted and based on the proposal form and the medical examination, the Opposite Party had issued the policy after excluding “all complications directly or indirectly related to the surgeries or procedures performed previously hysterectomy for the 1st four years of policy”. According to the Opposite Party, the Complainant had intimated two cashless claims to the Opposite Party during the aforesaid policy period. The Opposite Party received a pre authorization request from Vinayaka Hospital on 01.04.2020 stating that Complainant was provisionally diagnosed with unstable Angina. On getting the pre authorization request, the Opposite Party had issued a query letter dated 02.04.2020 for submitting documents viz, (1) Copy of 1st consultation reports (2) Copies of investigation like ECG, Tropt, Echo, CAG & trop-t, TMT (3) Copy of case sheets, and (4) Case sheets regarding previous history or episodes of heart diseases and as reply to the query letter, the hospital authorities had forwarded the medical records as per which the Complainant had history of wide excision for squamous cell carcinoma forehead on 17.10.2017. It is submitted by the Opposite Party that squamous cell carcinoma (SCC) is the second most common form of skin cancer which is usually found on areas of the body damaged by UV rays from the sun or tanning beds which is a fairly slow growing skin cancer. According to the Opposite Party, based on the available records, it is clear that the Complainant has been suffering from SQUAMOUS CELL CARCINOMA since 17.10.2017 which is prior to inception of the 1st policy and failed to disclosure the same in the proposal form which amounts to concealment of material facts. Hence the Opposite Party rejected the authorization, vide letter dated 06.04.2020. The Opposite Party states that Opposite Party had received an intimation of claim from Leo Metro Hospital on the admission of Complainant on 03.05.2020, and provisionally diagnosed with Coronary Artery Disease and was planned for PTCA, since the Complainant had suppressed the disease in the proposal form at the time of taking policy the claim was rejected by the Opposite Party. According to the Opposite Party the Complainant was suffering from SQUAMOUS CELL CARCINOMA since 17.10.2017 prior to inception of the 1st policy. The Opposite Party states that, in the proposal form in Health History Column question No.2 “Has the person proposed for insurance consulted/diagnosed/taken treatment/ been admitted for any illness/ injury. If yes details” – It is answered No by the Complainant. In question No.4 “Has the person proposed for insurance ever suffered or suffering from any of the following – (g) cancer, pre cancerous lesion – if yes since when” - it is answered No by the Complainant. For another question (m) “Any other problems (Pl specify)”- Complainant has answered No. In these circumstances, as per condition 7 of the policy the company shall not be liable to make any payment and hence rejected the authorization for the cashless treatment, vide letter dated 03.05.2020. It is stated by the Opposite Party that after discharge from the hospital, the Complainant had not approached the Opposite Party for reimbursement of the claim and hasn’t submitted any original documents/bills before the Opposite Party. Opposite Party states that as per condition 13 of the policy, a notice dated 17.04.2020 was issued to the Complainant and the policy was cancelled with effect from 27.05.2020 and returned the premium amount of Rs.8,674/- vide letter dated 18.06.2020.
4. The allegation that the agent is aware about the treatment in 2019 and she had revealed everything to the agent are not fully correct and hence denied. According to the Opposite Party the proposal form was filled by the Complainant and she is the one who put her signature in the form and hence there is suppression of material fact about the pre existing disease. Hence Opposite Party stated that there is no deficiency of service or unfair trade practice from the side of the Opposite Party and hence prayed for dismissal of the complaint with compensatory costs to the Opposite Party.
5. Evidence in this case consists of the oral testimony of PW1 and Exts A1 to A8 from the side of the Complainant and the oral evidence of OPW1 and Exts.B1 to B9 from the side of the Opposite Party.
6. Heard both sides and perused the records.
7. The following are the main points to be analysed in this complaint to derive in to an inference of the fact.
- Whether the Complainant had sustained to any deficiency of service or unfair trade practice from the side of the Opposite Party?
- If so the quantum of compensation and other reliefs for which the Complainant is eligible to get?
8. Ext.A1 is the copy of Medi Classic Insurance Policy (Individual) in the
name of the Complainant. Ext.A2 is the claim form with claim intimation No.0030714 dated 16.05.2020 submitted by the Complainant. Ext.A3 is the Discharge Summary from Leo Metro International Heart Care Hospital. Ext.A4 is the Coronary Angioplasty – Cath No.4239 of the Complainant. Ext.A5 is the Hematology Analysis Report of the Complainant of Leo Metro Hospital. Ext.A6 series is the bills for purchasing medicines for the Complainant. Ext.A7 is the letter of rejection of authorization for cashless treatment from the Opposite Party dated 03.05.2020. Ext.A8 is the certificate issued by Dr. Jyothish Vijay of Leo Metro Hospital, stating that the cardiac issues are in no way related to the squamous cells carcinoma.
9. The documents submitted from the side of the Opposite Party are marked as Exts.B1 to B9. Ext.B1 is the copy of Policy Schedule and conditions. Ext.B2 is the copy of proposal form. Ext.B3 is the request for cashless hospitalization from Vinayaka Hospital. Ext.B4 is the copy of query letter dated 02.04.2020. Ext.B5 is the copy of hospital records of Vinayaka Hospital. Ext.B6 is the copy of letter of rejection of authorization for cashless treatment dated 06.04.2020. Ext.B7 is the copy of request for cashless hospitalization for health insurance from Leo Metro hospital. Ext.B8 is the rejection of authorization for cashless treatment dated 03.05.2020. Ext.B9 is the copy of cancellation letter dated 17.04.2020.
10. The specific case of the Complainant is that due to suffocation and chest pain, she was initially taken to Vinayaka Hospital Sulthan Bathery and due to recurrent chest pain she was referred to Leo Metro Cardiac Centre, Kalpetta on 03.05.2020 and treated as inpatient No.18884 and discharged on 06.05.2020. The Complainant had intimated the claim to the Opposite Party but due to lock down they could not process the file for cashless scheme and offered reimbursement. The Opposite Party obtained entire documents on 16.05.2020, but letter of repudiation of claim was seen prepared on 03.05.2020 amounts to unfair trade practice. On the other hand the case of the Opposite Party is that the Complainant has not revealed the pre existing disease in the proposal form except that she had undergone uterus removal in 2014 which is the base and integral part of the contract on the basis of which the policy is issued. Since the Complainant was above 50 years of age a pre medical examination was conducted and policy was issued after excluding “All complications directly or indirectly related to the surgeries or procedures performed previously hysterectomy” for the 1st four years of the policy. According to the Opposite Party, as the reply to the query by the Vinayaka Hospital reveals that the Complainant had history of wide excision for squamous cell carcinoma forehead on 17.10.2017, which is 2nd most common form of skin cancer according to the Opposite Party. The medical records reveals that the Complainant had the said disease since 17.10.2017 which is prior to the inception of the 1st policy which fact is concealed by the complainant at the time of taking the policy. The Complainant was examined as PW1 but nothing was brought out to discredit the case of the Complainant. The son of the Complainant was examined as PW2 who deposed that “A½bv¡v hysterectomy Ign-ªn-«p-s¶pw BI-bm policy FSp¯v \mep-hÀjw policy coverage In«n-söv a\-Ên-em-¡n-bn-«pv ” . He further deposed that “2017 Ime-L-«-¯n A½bv¡v Hcp adpIv s\än-bn Dm-bn-cp-¶Xv remove sNbvXn-cp-¶p. CXv tImgn-t¡mSv WIMS  h¨m-bn-cp-¶p. squamous cell carcinoma F¶ AkpJw skin cancer sâ second most common form BsW¶v ]d-ªm s\än-bn Hcp adpIv am{X-am-bn-cp-¶p. AXv remove sNbvX Imc-y-§Ä ]d-ªn-cp¶p F¶m agent sNbvXn-«n-Ãm-¯-XmImw þ proposal form Â. Agent s\Xnsc \S-]Sn FSp-¯n-«nÃ. Agent tIkn I£n-bà ” . In Re examination PW2 deposed that “claim sNbvX hnj-b-hp-ambn bmsXmcp _Ôhpw tcmK-¯n-\n-sö certificate lmP-cm-¡n-bn-«pv Ext.A8”. In cross PW2 deposed that “Sn tcJ Rm³ Bh-i-y-s¸« {]Im-c-amWv tUmIvSÀ X¶-Xv”.
11. During cross examination of OPW1, he deposed that “2017  patient \v cell carcinoma Dm-bn-cp-¶-Xn\v B5 tcJ lmP-cm-¡n-bn-«p-v. 17.10.2017 emWv s\än-bn-emWv surgery sNbvXXv. claim sNbvX disease cell carcinoma bpamWv _Ô-an-söv tcJ-bn-ep-v”. OPW1 further deposed that “ All complication directly/indirectly h¶m am{X-amWv policy exclude sNbvXq F¶v affidavit  4th para  ]d-ªn-«p-f-fXv patient \v hysterectomy related surgery and complications h¶ncp¶Xn-\m-emWv \mep hÀj-t¯¡v claim In«n-sÃ-¶mWv ]d-ªn-«p-f-f-Xv. adpIv disease BtWm F¶v t\m¡n-bse ]d-bm³ Ign-bq”. OPW1 further deposed that “Discharge Summary e`n-¨n-cp-¶nà treatment records BWv \ÂIn-bXv ECG s]mep-ff tcJ-Ifpw In«n-bn-à AsXm¶pw affidavit  ]d-ªn-«n-Ô. OPW1 further stated in cross examination that “ claim sNbvX disease Bbn«p _Ô-s¸-«-Xà carssinoma F¶v ]d-ªm icn-bm-Wv. ]t£ carssinoma suppress sNbvXmWv policy FSp-¯-Xv”. A perusal of documents from either side shows, the Complainant was admitted in Vinayaka Hospital during 10/2017 and later admitted in Leo Metro Hospital during 5/2020. At the time of taking the policy in 2017, the case of the Opposite Party is that the Complainant had not disclosed the pre existing disease while taking the policy. But according to the Complainant, the earlier admission in the hospital was for removing a pimple. Ext.B5 shows the history of surgical wide excision of squamous cell carcinoma forehead done. It is also stated in Ext.B5 that “no history of Diabetes Melitus (DM)/ Coronary Artery Diseases (CAD)/ Ceribro Vaxular Accident (CVA)”. Ext.A8 certificate from the cardiologist from Leo Metro Hospital shows “her cardiac issues are in no way related to the squamous cell carcinoma. The two are totally independent diseases”. Considering Ext.B5 &A8 together shows that the surgery conducted in 2017 and the subsequent hospitalization due to cardiac problem are no way related to each other. But the basic argument of the Opposite Party is that the fact of surgery in 2017 is not mentioned in the proposal form. The Complainant answered “No” to the specific question in the Health history column which amounts to suppression of material facts and hence as per the policy condition, the claim is to be rejected.
12. The Commission upon making a very thorough examination on the overall aspects of the case has observed that the Complainant who has subscribed into the policy with the Opposite Party in 2019 as per the documents. Being a woman aged above 50 years of age she was subjected to medical check up before issuing the policy by the Opposite Party. Obviously any ailment prevailed during the time of medical examination had been brought out by the physician concerned. In the instant case there is no claim from the side of the Opposite Party that such a disease as stated in the version (Carcinoma) has been diagnosed. Instead of that it is only stated that based on some other evidences that the Complainant had under gone surgery for carcinoma, which has not been disclosed by the Complainant at the time of taking the policy. Complainant is only a layman who is not medically educated to diagnose a disease even if it is affected to her. A scar or a pimple or a mole occurred in the body shall ordinarily never be considered as cancer by a layman. In the instant case the claim is preferred not for an ailment of cancer but for cardiac problem. The Opposite Party had not produced any evidences to substantiate that the cardiac arrest of the Complainant had occurred due to carcinoma vice versa the Complainant had produced Ext.A8 stating the cardiac issues are no way related to squamous cells carcinoma and therefore the repudiation of the claim by the Opposite Party on the basis of suppression of pre existing ailment is baseless as far as this particular case is concerned and point No.1 is found in fvour of the Complainant. Hence the following orders are passed.
- Opposite Party is directed to pay an amount of Rs.1,40,814/- (Rupees One Lakh Forty thousand Eight hundred and Fourteen only) paid by the Complainant as hospital expenses with 6% interest.
- Opposite Party is liable to pay compensation of Rs. 20,000/- (Rupees Twenty thousand only) to the Complainant.
- Opposite Party is also liable to pay an amount of Rs.5,000/- (Rupees Five thousand only) towards cost of the proceedings.
Needless to say that the above ordered amounts shall be paid within 30
days of receipt of copy of this order other wise the Opposite Party will be liable for 9% interest for the amount from the date of complaint till realization except for the amount awarded as costs.
Hence CC partly allowed.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 22nd day of July 2024.
Date of filing:02.06.2020.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Omana. Complainant.
PW2. Tinto Varghese Engineer.
Witness for the Opposite Party:
OPW1. Balu. M. Deputy Manager – Legal.
Exhibits for the Complainant:
A1. Mediclassic Insurance Policy (Individual) Schedule.
A2. Claim Form- Part A. dt:16.05.2020.
A3. Discharge Summary.
A4. Coronary Angioplasty – Cath No.4239.
A5. Hematology Analysis Report.
A6(a) Bill. dt: 05.05.2020
A6(b) Bill. dt:04.03.2020.
A6(c) IP Bill Breakup Details. (Page No.1) dt:06.05.2020.
A6(d) IP Bill Breakup Details. (Page No.2) dt:06.05.2020.
A6(e) IP Bill Breakup Details. (Page No.3) dt:06.05.2020.
A6(f) Inpatient Invoice Summary. dt:06.05.2020.
A6(g) Bill. dt:04.05.2020.
A6(h) Bill. dt:04.05.2020.
A6(i) Bill dt:03.05.2020.
A6(j) Bill. dt:03.05.2020.
A6(k) Bill. dt:06.05.2020.
A6(l) Bill. dt:04.05.2020.
A7. Copy of Letter. dt:0305.2020.
A8. To Whom So ever It May Concern. dt:31.05.2022.
Exhibits for the Opposite Party:
B1. Copy of Letter. dt:24.07.2019.
B2. Copy of Common Proposal Form.
B3. Copy of Request for cashless Hospitalisation for Health Insurance.
B4. Copy of Letter. dt:02.04.2020.
B5. Copy of Hospital Records of Vinayaka Hospital.
B6. Copy of Letter. dt:06.04.2020.
B7. Copy of Request for Cashless Hospitalisation for Health Insurance.
B8. Copy of Letter. dt:03.05.2020.
B9. Copy of Letter. dt:17.04.2020.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
