By. Smt. Renimol Mathew, Member:-
Brief of the complaint:- The complainant had a Medical Insurance Policy No. 101602/48/11/06/00000691 with effect from 29.07.2011 to 28.07.2012. During the subsistence of the policy complainant's daughter became ill and treated. Then complainant put forward claim form by producing all relevant records to opposite party No.1. Though opposite party No.1 has accepted the claim and acknowledged the receipt of the documents, the claim amount has not been disbursed so far in spite of repeated demands. Subsequently the complainant received a letter from TPA on 12.12.2011 that he is only entitled to get Rs.50,000/- as claim amount. Thereafter the complainant received Rs.50,000/-. According to complainant this act of opposite parties are deficiency of service. Hence filed this complaint to get entire claim amount.
2. Notice served to opposite parties. Opposite party No.1 appeared and filed version. Opposite party No.2 not present before this Forum, hence set ex-parte on 01.03.2013 and proceeded with the case.
3. Opposite Party No.1 filed version in short it is as follows:- The complainant had taken an Individual Family Medicare Policy from this opposite party for the period starting from 28.07.2008 to 27.07.2009 to cover sum of Rs.50,000/- and subsequently renewed the same for the period 28.07.2009 to 27.07.2010 and from 29.07.2010 to 28.07.2011 and the complainant enhanced the sum insured to Rs.5,00,000/- from 29.07.2011 to 28.07.2012. As per the policy of insurance the complainant, his wife Ancy John, his son Arun John, Ajay John and his daughter Anju John were covered. While the complainant submitting the proposal form he has suppressed the material fact regarding the pre-existing disease of his daughter Anju John who had treated at NIMHANS for Bilateral Coronal Synostosis treatment at 1 year of age during 2003 and the daughter of the complainant Anju John was admitted in the Narayana Hrudayalaya Hospital on 01.07.2012 due to Craniosynostosis with a history of intermittent head ache and eye pain commenced since one year. This intermittent head ache and eye pain was reported from 01.07.2011. And the treatment was given for increased intra cranial Pressure and Acrino plasty and Fronto Orbital advancement to increase intra cranial volume. The maximum liability covered as per the policy covering the date 01.07.2011 was Rs.50,000/-After the receipt of the claim form from the complainant this opposite party processed the claim and forwarded to the opposite party No.2 for further action. As per the terms and conditions of the policy the complainant is entitled to get sum of Rs.50,000/- since the disease was started during the earlier policy period as per that policy the maximum liability of this opposite party was Rs.50,000/-. Hence the complainant is not entitled to get any further amount as claim amount. Hence opposite Party No.1 prays for the dismissal of the complaint.
4. On considering the complaint, version and documents the following points for consideration:-
1. Whether there is any deficiency of service on the part of the opposite parties?
2. Relief and Cost.
5. Point No.1:- The complainant filed affidavit and examined as PW1. Ext.A1 to A6 documents were also marked. Ext.A1 Series are the Insurance Policy documents. Ext.A2 is the copy of Medical Certificate. Ext.A3 is the Copy of Lawyer Notice. Ext.A4 is the Acknowledgment Card. Ext.A5 is the Letter from opposite party No.2. Opposite party produced Ext.B1 to B9 documents to prove that the treated disease is a pre-existing one. Ext.B1 is the Proposal Form, Ext.B2 is the Family Medicare Policy, Ext.B3 is the Health Insurance Policy Claim Form, Ext.B4 is the Medical Certificate from Narayana Hrudayalaya, Ext.B5 is the Discharge Summary, Ext.B6 is the Carnio-facial case Record, Ext. B7 is the Operation Note, Ext.B8 is the Non-Contrast CT Face and Brain and Ext.B9 is the OP case sheet from Naryana Hrudayalaya. On verification of Clinical Notes, Doctors' Certificate and Discharge Summary it is clear that the treated disease is the continuation of the treatment done at NIMHANS in the year 2003. The hospitalization and period of policy coverage is admitted by opposite party No.1. The only dispute regarding the claim is that whether the complainant is entitled to get the entire hospitalization expenses. To prove this aspect first of all it is necessary to prove that whether the treated decease is a pre-exsisting one or not. The complainant submitted that he consulted the treated doctor with his daughter only on 11.06.2012 with the symptome of head ache and eye pain and the patient was admitted there from 01.07.2012 to 09.07.2012 for carnioplasty with Fronto orbital advancement operation. Before that he has no knowledge about this decease so the treated disease is not a pre-existing one. But opposite party contented that while submitting the proposal form the complainant suppressed the material fact regarding the pre-existing desease of his daughter Anju John, she was treated in NIMHANS Banglore for Bilateral Coronal Synostosis at one year of age during 2003. Now the present treatment taken from Narayana Hrudalaya Hospital at her age 10 on 01.07.2012 due to Craniosynostosis with a history intermittent head ache and eye pain commenced since one year as per claim form and medical certificate. The intermittent head ache and eye pain was reported from 01.07.2011 and the treatment was given for increased intra carnial pressure and Acrino plasy and Fronto Orbital advancement to increase intra Carnial Volume. This treatment is related to Bilateral Coronal Synostosis treated in the early age of 1 of Anju John from NIMHANS. After the receipt of the claim form opposite party No.1 forwarded the same to opposite party No.2 for further action.
6. Again opposite party submitted that formerly complainant had taken an Individual Health Insurance Policy for a sum of Rs.50,000/-, subsequent renewals were done. On 28.07.2011 the complainant converted the Individual Health Insurance Policy to Family Medicare Policy and enhanced the sum insured to Rs.5,00,000/-. As per the Ext.A2 Medical Certificate given by the treated Doctor in column No.12 it is specifically stated that “History of illness – past one year”. Again Opposite party No.1 submitted that they forwarded the claim form to opposite party No.2, they replied that since present complaint of intermittent head ache and eye pain commenced since one year ie within the Individual Health Insurance Policy Period (Ext.B1) from 29.07.2010 to 28.07.2011, the maximum liability of this policy was Rs.50,000/- only. Accordingly the claim of the complainant was settled for maximum sum insured Rs.50,000/- considering the date of commencement of intermittent head ache and eye pain. Opposite party again argued that the conversion of the policy from Individual Health Insurance Policy to Family Medicare Policy and enhancement of the sum insured Rs.50,000/- to Rs.5,00,000/- by the complainant was anticipating the future treatment of his daughter. But complainant argued that complainant have no knowledge about the pre-existence of the disease. The subsequent admission in Narayana Hrudalaya is not the continuation of the treatment done at NIMHANS in the year 2003, without his knowledge the treated Doctor mentioned the history of past one year in Ext.A2. Moreover that in Family Medicare Policy No.101602/48/12/06/00000382, Page 5 Clause 4 Exclusions 4.1 “Pre-Existing Condition/Disease definition – Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to his/her first policy with the company”. Inception of the policy was in the year 2008. As per the policy exclusions complainant need to disclose the decease history from 2004 onwards. In this case the previous treatment was taken in the year 2003. On going through the evidences and records the Forum finds that as per the policy exclusions of Ext.B2 complainant is entitled for entire claim amount. The Point No.1 is found accordingly.
7. Point No.2:- Since the Point No.1 is found in favour of the complainant. Hence the complainant is entitled to get entire claim amount with cost and compensation. Point No.2 is found accordingly.
In the result the complaint is partly allowed. The opposite party No.1 is directed to pay the complainant Rs.2,71,939/- (Rupees Two Lakh Seventy One Thousand Nine Hundred and Thirty Nine Only) with 6% interest from 23.07.2012 till full payment. The Opposite party No.2 is directed to pay Rs.3,000/- (Rupees Three Thousand Only) to complainant as cost and compensation. This Order must be complied by the opposite parties within 30 days from the date of receipt of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 19th day of August 2014.
Date of Filing:17.12.2012.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. John Joseph. Complainant.
Witness for the Opposite Parties:
OPW1. Sajeevan. Manager, United India Insurance Co Ltd,
Sulthan Bathery Branch.
Exhibits for the complainant:
A1(Series). Insurance Policy Documents.
A2. Copy of Medical Certificate.
A3. Copy of Lawyer Notice. Dt:11.10.2012.
A4. Copy of Acknowledgment Card.
A5. Copy of Letter. Dt:03.12.2012.
A6. Family Medicare-Prospectus.
Exhibits for the opposite Parties.
B1. Proposal Form.
B2. Family Medicare Policy.
B3. Health Insurance Policy Claim Form.
B4. Medical Certificate.
B5. Discharge Summary (5 pages).
B6. Cranio- Facial Case Record.
B7. Operation Note.
B8. Non-Contrast CT Face and Brain. Dt:11.06.2012.
B9. OP Case Sheet (5 Pages).
Sd/-
PRESIDENT, CDRF, WAYANAD.
