BY - SRI ASISH DEB, PRESIDENT
Brief facts of the complainant’s case is that your complainant is a permanent resident of the above noted address and a Senior and Elderly citizen of India by birth. OP No.1 & 2 are a well known Insurance Company providing Senior Citizens Red Carpet Health Insurance Polity to the elderly consumers. The complainant being a bonafide consumer, availed and renewed a yearly Senior Citizens Red Carpet Health Insurance Policy from the Ops vide Policy No. P/191133/01/2020/007506, which had been subsequently renewed for the next year vide Policy No. P/619019/01/2021/000356, for a the Sum Insured as Rs. 10,00,000/-(Ten Lakhs Only) by paying the premium of Rs. 26550/- and her daughter namely Mrs. Sangita Sautya being the Proposer of the said policy. The customer ID of your complainant for the above policy being 14113962-1 valid from 06.03.2020. During the issuance of the policy your complainant had to declare her pre-existing diseases like Hypertension and its complications, and hence she had to pay a higher amount of premium for the same. During the continuance of the above renewed policy, suddenly your complainant was affected by Covid-19 and after recovery she felt some breathing troubles, for which she was taken to the AIG Hospital, Mindspace Road, Gachibowli, Hyderabad, Telengana 500032, where she was admitted on 15.09.2021. Your Complainant was diagnosed as “ a known case of Hypertension, post Covid status (2020 sep), osteoarthritis kne4es, Carpal tunnel Syndrome, irritable bowl syndrome, presented with complaints of shortness of breath” and she was advised to undergo an “AORTIC VALVE REPLACEMENT SURGERY WITH 19MM, EDWARDS PERIMOUNT MAGNA EASE VALVE” (in short, AVA Surgery). Be it specifically mentioned here that neither of the above diseases are related with heart disease and all these are utmost common in every elder citizen. The fact was instantly intimated to the OP companies who initially and verbally assured that the treatment and surgery shall be done on “Cashless” basis, but ;later they advised to go for the surgery on immediate basis and they promised to indemnify the same in due process and mentioned in their official claim document that “cashless is closed/rejected”. Your complainant was admitted since 15.09.2021 till 21.09.2021, the surgery being done on 17.09.2021, and a total bill was paid for the same to the tune of Rs. 633662.00/-. After the discharge on 21.09.2021, again your complainant felt some post operative complications like shortness of breath, and again she was admitted at the same hospital under the same doctor from 24.09.2021 till 30.09.2021, and this time a bill of Rs. 73,485/- was paid by her. Claim for reimbursement of the policy amount amounting Rs. 633662 + Rs. 73485 was immediately made to the Ops by following all procedures along with documents and treatment papers and the some additional documents were also demanded by the Ops. Thereafter a long delay and dillydallying was made by the Ops jointly and severally, and lastly it came to known to your complainant that her claim has been whimsically and in an utmost concocted way, rejected by assigning reason of suppressing previous disease mentioned as “The insured patient had Rheumatoid Arthritis (RA) 10 years back” on 03.01.2022. The Ops completely ignored the fact that the operation was done for a sudden ailment, which has been clearly mentioned in the Discharge Summery of AIG Hospital Hyderabad, and the gross negligent act and deficiency in service of the Op not only ruined the life of your complainant and his family, but also caused a serious mental agony and pain by rejecting his valid legal Mediclaim. Therefore, your complainant is hereby initiating this case before the Ld. Commission seeking Redressal against the negligence and deficiency in service done jointly and severally by all the Ops, praying for the following reliefs and the Ld. Forum has enough jurisdictions to entertain this case. The cause of action of this case arose on and from the date of Repudiation of Medicalim demand on and from 03.01.2022 done by the Ops and continued till date. All the relevant documents and paper are filed herewith in Xerox Copies. In these circumstances it is accordingly prayed that your Ld. Forum may graciously be pleased to pass the following orders against the Ops. By directing them jointly and severally to pay a consolidated sum of Rs. 633662 + 73485= 707147/- (Seven Lakhs Seven Thousand One Hundred Forty Seven Only) plus an interest of Rs. 18% p.a. till the full and final recovery of the Medicalim Policy. Directing the Ops to pay a sum of Rs. 150000/- towards compensation, costs, mental agony and suffering s of your complainant due to shear negligence, and deficiency in rendering medical service by the Ops. To direct the Op to pay Rs. 20000/- only towards litigation cost. To pass such other orders of relief as the Ld. Commission may deem fit and proper.
Summon was issued upon the Opposite Parties. Despite service of summon the OP did not appear to contest the case. Hence, the case is heard ex-parte against the OPs.
Points for determination are:
1. Is the case maintainable in its present form and in law? 2. Is the Complainant entitled to the relief(s) as sought for?
Decision with reasons
Both the points, being inter related to each other, are taken up together for discussion for sake of brevity and convenience.
We have carefully perused the affidavit of the complainant and evidence produced by the Complainant .The complainant is consumer. In the facts and circumstances, the case is maintainable in the present form and in law,
For proper adjudication of the rival stands in this case relevant averments of the two documents viz repudiation letter of the op and discharge summery of the patient /complainant filed by the complainant require to be reproduced.
Repudiation letter
We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of bicuspid aortic calve.
Although, the present admission of the insured patient is for treatment of bicuspid aortic valve, it is observed from the consultation report dated 04.10.2021 of above hospital, the insured patient has rheumatoid arthritis (RA) for the past 10 years which is prior to date of commencement of first year policy.
At the time of inception of policy which is from 06/03/2020 to 05/03/2021, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. Had you disclosed the above pre existing disease/s in the proposal form we would not have issued the policy.
As per Condition No. 6 of the policy issued to you, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not.
- Discharge summery
Clinical History
A 61 years old female is a known case Hypertension, post covid status (2020-Sep), osteoarthritis knees, carpal tunnel syndrome, irritable bowel syndrome, presented with complaints of Shortness of breath. On evaluation CAG (21/08/2021) was done, which revealed normal study. @D Echo revealed: Concentric LVH, thickened papillary muscle causing mild mid cavity with peak gradient of 38mm Hg, Bicuspid aortic valve, Severe AS, Trivial AR, NO RWMA, normal LV systolic function, trivial TR, NO PAH, no pericardial effusion/ no LV clots. Advised: AVR Surgery.
Now, according to repudiation letter insured complainant had pre-existing rheumatoid arthritis (RA) but the complainant’s discharge summery shows Clinical History A 61 years old female is a known case Hypertension, post covid status (2020-Sep), osteoarthritis knees. The words do not find place in the discharge summary; the ops have not come to commission to face the questionnaire from where they imported the cause of repudiation as rheumatoid arthritis (RA),
Osteoarthritis has often been referred to as a wear and tear disease. It is the most common form of arthritis, effecting millions of people worldwide . It occurs when the protective cartilage that cushion the ends of the bones wears down overtime .It is a degenerative joint disease which has no direct nexus with the disease suffered by the complainant.
Rheumatoid arthritis (RA) can lower quality of life. It can cause pain disability and premature death. People with RA are also at at risk for developing other chronic disease as much as heart diseases and diabetes.
The complainant’s evidence has remained unchallenged. The complainant has got the valid insurance policy with the op insurance company. The complainant has not claimed reimbursement or any PED. Artheritis has got no connection or impact with the disease for which the patient was treated. The unmerited repudiation by the ops has set an instance of serious deficiency of service, negligence and harassment to the consumer complainant. In view of the benefits of the valid insurance policy the complainant is entitled to get the limited amount of Rs. 3,50,000/- for the sum assured as per terms and condition of the policy reimbursement of the costs of hospitalization expenses for treatment of bicuspid aortic calve.) , compensation of Rs.5000/- and Rs.5000/- as towards costs litigation.
Thus both the points are decided in favour of the complainant.
Hence, it is
O R D E R E D
That CC/31 of 2022 be and the same is allowed ex parte against the OP.
The Opposite Parties ,who are jointly and severally liable, are hereby directed to pay a sum of Rs.3,50,000/-as costs of hospitalization expenses for the treatment and compensation of Rs.5,000/- to the complainant along with interest @ 7% p.a. from the date of filing of this case till full realization of the awarded amount with further Rs. 5000/- as litigation cost, within one month from the date of this order, failing which the complainant will be at liberty to put this order into execution.
Let copy of the judgment be supplied to all the parties free of cost.
