Order-14.
Date-27/07/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short compass is that the Complainant availed one Medical Policy coverage from the OP Insurance Company being Policy No., 120100/12001/2014/A003873/432(ID 10007559134) with a coverage of Rs.5 lacs Per Annum and the same has been renewed from time to time till date. Unfortunately, the Complainant became ill and she was admitted in Apolloo Gleanegles Hospital, Kolkata on August 14, 2016 under the supervision of Dr. Syamasis Mukhopadhyay with some symptom of severe anemia . The Complainant was discharged from the Hospital on August 29, 2016. The Complainant for treatment and also for various tests, paid a sum of Rs.2,97,953.04 towards Hospital dues. The Complainant submitted a claim form before the OPs along with original documents, prescription, Bill etc. But surprisingly the OPs repudiated the claim of the Complainant on August 29, 2016 or the ground that the Complainant is suffering from ‘Heart disease’. The Complainant receiving the said repudiation letter on October 03,2016, on 03.10.2016 sent a mail to the OPs pointing out that she has never been a patient of heart disease and she was also very much willing to continue her Health Policy. The OPs, thereafter, had given an approval of Rs.40,000/- to Complainant. But all on a sudden on October 24, 2016 they sent a mail stating that they repudiated the claim with the ground of non information of hip replacement. Complainant thereafter sent a legal notice to the OPs, but to no response from the side of the OPs. It is stated that the OPs have been deficient in rendering service to the Complainant and they have also indulged in unfair trade practice and have caused mental agony, harassment and injury to the Complainant.. The Complainant stated that she is entitled to get a sum of Rs.2,97,953.04 towards the hospital dues and also to compensation and other reliefs in terms of prayers in the instant complaint.
OPs have contested the case in filing w.v. contending inter alia that the Complaint is devoid of merit and is not maintainable in fact and in law. It is stated that in clause 4 of the Insurance Policy, it is stated that the insured at the time of entering into such policy must confirm that the members proposed to be insured under this policy are in good health and have not suffered in last 05 years from any major disease/ disorder/ailment or deformity (other than in frequent common cold, fever, loose motion, headaches, acidity, high cholesterol, asthma, thyroid problem, diabetes without any complication, or hypertension without complication).
It is stated that on 16.8.2016 cashless was received from Apollo Gleneagles Hospital in Kolkata for the Complainant Leela Bharati who had gotten admitted with c/o shortness of breath, chest discomfort and probable diagonosis of anemia ? / Sepsis with date of admission being 14.08.2016 and estimated duration of stay of 4 days and estimated cost of Rs.80,000/-. It is also stated that post receiving the documents, it was noted that the available documents are not sufficient to process the Cashless, so a query was raised to provide past history. Later on, initial approval was given for Rs.40,000/- on the basis of available documents. But, later on an enhancement request for the already pre-approved amount was received with further medical documents. It was noted from the provided medical documents that the Compolainant has a history of total Hip replacement, so queries were raised vide letter dated 21.08.2016, 22.08.2016 and 27.08.2016 to get details related to past illness i.e. hip replacement surgery. Post revewing the reply so received, it was noted that Complainant has history of THR since 2013. It is alleged that this material information had not been disclosed by the Complainant’s husband in the enrolment form and accordingly, cashless was rejected vide letter dated 28.08.2016 for in correct declaration of matrial facts. The Policy of the Complainant vide letter dated 12.10.2016 was also cancelled since the insured complaint had not disclosed her medical condition at the time of application for health insurance coverage and had obtained the insurance through incorrect good health declaration. It is stated that the OP received a claim lodged by the Complainant for an amount of Rs.2,97,953.04 for reimbursement of expenses incurred on account of hospitalization at the Apollo Glengeales Hospital at Kolkata from 14.08.2016 to 29.08.2016.
In view of non disclosure of material facts and on the basis of which cashless had been denied and Policy had been cancelled, the OPs did not consider the claim of the Complainant. It is stated that Insurance is a contrct between the parties and breach of duty by the Insures entitles to insurer to avoid the contract of Insurance. It is stated that the present complaint is false, frivolous and been filed to obtain unjust monetory gain and is liable to be dismissed.
Point for Decision
- Whether OPs have been deficiernt in rendering service to the Complainant?
- Whether the Complainant has acted it contrary to Clause 4 of the Enrolement form?
- Whether the Complainant is entitled to get relief as prayed for?
Decision with Reasons
We have perused the documents filed on behalf of the Complainant i.e. photocopy of of welcome letter along with terms and conditions, photocopy of Hospital list, photocopy of prescription of Dr. Santosh Kr. Maheshwari, photocopy of discharge summery of Apollo Gleneagles Hospital dated 29.08.2016, photocopy of Notice for permission dated 29.08.2016, photocopy of duly filled-in claim form, photocopy of letter of rejected cashless facility, photocopy of legal notice and other documents as filed from the side of the Complainant.
We have also perused the documents filed from the side of the OP Insurance Company i.e. Photocopy of Power of Attorney, photocopy of certificate of Insurance Health, photocopy of pre-authorisation form, photocopies of letterrs for additional information dated 21.08.2016, 22.08.2016 and 27.08.2016, photocopy of discharge summery dated 03.06.2013 of Apollo Gleneagles Hospital, photocopy of letter of denial of Cashless service dated 26.08.2016, photocopy of letter of cancellation of Policy for non disclosure of material fact dated 12.10.2016, photocopy of discharge summary dated 12.10.2016 and other documents as filed from the side of the OP Insurance Company.
In the instant case the Complainant has made allegations of illegal repudiation of Insurance Policy being No. 120100/12001/2014/A003873/432(ID 10007559134). The Complainant was admitted in Apollo Gleanegles Hospital under the close supervision of Dr. Syamasis Bandopdhyay with the main symptom severe anemia . We also find that the Complainant was under supervision of Dr. Santosh Kumar Maheswari since long and as per his treatment the Complainant was admitted in Apollo Gleanegles Hospital on August 14,2016. We have seen the prescription of Dr. Santosh Kumar Maheswari dated 12.08.2016. We find that there is clear mention of Hip replacement two years back and Rheumatoid Arthritis, low back pain radiating to both legs, difficulties in walking and standing. Dr. Maheswari, however, also treated her on 13.08.2016 when he advised immediate hospitalization as her haemoglobin was 4.8 gm. She was admitted in Apollo Gleanegles Hospital on 14.08.2016. In discharge summary, we also find she was diagonosed .-
“ Rheumatoid Arthritis (Steroid Dependant Pallindromic), Hypertension, Lower Respiratory Tract Infection, Osteoarthritis Knee, Severe Anaemia, Esophageal Candiddiasis & Antral Ulcer “.
Complainant in his petition of complaint has stated that the OP repudiated the claim of the Complainant on August 29,2016 with a ground that Complainant is suffering from ‘Heart disease’. But, we find that it is not so. In fact the claim was repudiated in view of non disclosure of - past history of Hip Replacement in 2013 prior to policy inception. It is stated by the OPs that Hip Replacement in 2013 was not declared at the time of Policy inception.
We find that one of the terms of the policy as more fully specified in the Enrolement form under clause - 4 . - “ Declaration and Warranty on Behalf of all Persons to be Insured “ is . - that at the time of entering into such policy the insured must confirm that the members proposed to be insured under this policy, are in good health and have not suffered in last 5 years from any majaor disease / disorder / ailment or deformity )other than infrequent common cold, fever loose motion, headaches, acidity, high cholesterol, asthma, thyroid problem, diabetges without any complication, or hypertension without any comnplication). Further it has been clearly stated that Declaration made there in by the person proposed to be insured, shall act as basis for respondent company to decide whether to cover or not to cover persons proposed to be insured under insurance”.
As per IRDA (Policy Holders Interests) regulations 2002 Section 2(d) “ Proposal form means a form to be filled-in by the proposer for Insurance for furnishing all material information required by the Insurer in respect of a risk, in order to enable the insurer to decide whether to accept or to decline, to undertake the risk, and in the event of acceptance of the risk to determine the rates, terms and condition cover to be granted”.
We observe that Complainant has not disclosed in the enrolement form / proposal form about the total Hip Replacement Surgery underwent by her in the year 2013, wherein she was required to disclose the good health declaration that she was in good health and has not suffered in last 5 years from any major disease / disorder / ailment or deformity. Complainant has not been honest in making such declaration. From the above, it can be easily concluded that the Complainant has deliberately not disclosed her past medical history. Moreover, we find that the policy was obtained by the Complainant on 24.09.2014 and was valid from 24.09.2014 to 23.09.2015 and was renewed from 24.09.2015 to 23.09.2016. We find that 36 months continuous coverage has not been elapsed since inception of the “ Easy Health Group Health Policy “ with the OPs.
We also find from the discharge summary of Apollo Gleanegles Hospital at Kolkata that the Complainant had taken admission at the said Medical Centre for “Rhematoid Arthritis (Steroid Dependent Pallindromic), Hypertension, Lower Respiratory Tract Infection, Osteoarthritis knee, Severe Anaemia, Esophageal Candidiasis & Antral Ulcer “. The very fact of Hip Surgery was not disclosed at the time of taking mediclaim policy The Complainmant has history of total Hip Replacement in 2013. The material information had not been disclosed by the Complainant in the enrolement form.
We find that Complainant did not disclose the material fact that she had past medical history of Hip Replacement in 2013. We also find that the present ailment is related to a pre-existing disease which was not disclosed to the OP, Good faith is the tenet of the insurance policy. Contract of Insurance is Contract of uberrima fides, i.e. a Contracrt of Good Faith. There is requirement of uberrima fides i.e. good faith on the part of the insured. We find that the Complainant obtained the insurance policy by not disclosing and/or suppressing material information which would have influenced the issuance of the policy in favour of the Complainant. We find that there are Clauses 6 and 7 which require the Complainant to make full and frank disclosure of best medical history. Answers given by the proposer therein are all ‘no’. All the questions as we find answered in negative by the insured regarding medical history. The repudiation of the claim and cancellation of the mediclaim policy by the OP cannot be said to be arbitrarily.
We think that the claim of the Complainant was validly repudiated on such ground. The discharge summery issued to Apollo Gleanegles Hospital specifies diagonosed as RA, Astrio Knee. It can be concluded that there has been cleare suppression of material fact and the Complainant is not entitled to anything contrary to the condition covered under the policy. It cannot be concluded that there has been deficiency of service on the part of the OPs.
[Perused the decisions reported in Authoity under Yeshashwini Wima Yojna Vs Mumtaz Begum – RP 1173/2007”, AIR 1999 SC 3252 - Oriental Insurance Co. Ltd. Vs. Sony Cheriyam / (2009) CPJ 117 (NC) – Diwan Surender Lal Vs Oriental Insurance Co. Ltd, Vikram Greentech (I) Ltd. Vs. New India Assurance Co. L.td. reported at (2009) 4 MLJ811 (SC)”, Gouri Sankar Agarwal Vs. Max Bupa Health Insurance Co. Ltd., Harjinder Kaur Dadiala Vs. National Insurance Company Ltd. & Anr., Ajit Santok chand Surana Vs. Nationial Insurance Co. Ltd., delivered on 4th May 2017 as cited from the side of OPs].
[Perused the decisions reported in (2017) CPJ 262 (NC), 1 (2017) CPJ 266 (NC), (2016) CPJ 339 (NC), (2016) CPJ 341 (NC) as cited by Ld. Lawyer for the Complainant]
Consequently, the case merit no success.
Hence,
Ordered
That the instant case be and the same is dismissed on contest against the OPs.
No order as to cost.
