FINAL ORDER/JUDGEMENT

SHRI SWAPAN KUMAR MAHANTY, PRESIDENT

Brief facts of the consumer complaint:-

Complainant filed the instant consumer complaint U/s 12 of the Consumer Protection Act, 1986 pleaded therein that he obtained a Health Insurance Policy bearing obtained a Health Insurance Policy bearing No. 140700/12001/2017/A006993/PE00459753 from OPs 1 & 2. Coverage of policy was Rs. 5,00,000/-. It is pleaded that on 12.02.2018 complainant was admitted to Apollo Speciality Hospsital at Chennai in the department of Medical Oncology and discharged on 23.02.2018. Complainant had lodged claim of Rs. 5,29,365/- to the OPs 1 & 2 for reimbursement against Claim ID No. 735773 with a self declaration that he had no prior history of Lymphoma. The OPs 1 & 2 repudiated the claim vide letter dated 25.06.2018. The OPs have committed deficiency in service. Finding no other alternative,  complainant has filed the instant consumer complaint before this Forum seeking redress and relief as incorporated in the prayer of the complaint.

Per-contra OPs 1 & 2 filed their WV  pleaded therein that  OP-3 Indian Overseas Bank was the master policy holder of “Easy Health Group Insurance Policy”.  Complainant enrolled himself in Easy Health Group Insurance Policy through OP-3. Sum insured of the policy was Rs.   5,00,000/-  and period of policy was 18.02.2018 to 17.02.2019. Complainant was admitted to Apollo Specialty Hospital, Chennai and his admission was for investigation and evaluation. Disease of complainant is pre-existing in nature. Thus, reimbursement  request of the complainant had been rejected and policy was cancelled. Hence, the answering OPs are not under obligation to pay reimbursement claim. Prayer for dismissal of consumer complaint sought.

The OP-3 also contested the complaint by filing WV alleging inter-alia that complainant is not a “Consumer” defined U/s 2 (d) of the CP, Act, 1986. Another contention of the OP-3 is that there is no deficiency of service or unfair trade practice on the part of the answering OP as the transaction transpired between the complainant and OPs 1 & 2. The specific case of the answering OP is that they acted as intermediary during sale of Health Insurance Policy and the insurance policy is governed by the terms & conditions of the policy document. The answering OP is not any way related with the settlement of claim of the complainant/insured. Hence, the answering OP has prayed for dismissal of the complaint with exemplary cost.

Decision with Reasons

The parties adduced evidences through examination in the chief. Parties have also filed their BNAs.  We have heard the arguments of the Ld. Advocates of the parties and have perused entire record carefully.

Short question for adjudication in this complaint is whether the claim of the complainant in the facts and circumstances of the case is payable. This leads to another question whether the claim is covered within the parameters of the policy or there exists any encumbrances.

The facts not in dispute are that complainant had approached the OP-1 insurance company for Mediclaim Policy under Easy Health Group Insurance, proposal form was duly filled in and signed by the complainant. Complainant accepted the terms & conditions of the policy being No.  140700/12001/2017/A006993/PE00459753 for the period 18.02.2018 to 17.02.2019. It is admitted by insured and insurer that complainant was admitted to Apollo Specialty Hospital, Chennai, in the department of Medical oncology on 12.02.2018 and discharged on 23.02.2018. A pre-authorization request was sent to the Insurer on the part of Apollo Specialty Hospital, Chennai for admission of complainant/insurer with estimated cost of Rs. 5,00,000/- for “lymphoma” and the OPs/Insurer denied of cashless service vide letter dated 21.02.2018 with certain reasons. It is also true that subsequently complainant submitted reimbursement claim of Rs.  5,29,365/- for his treatment for “Coronary Artery Disease with Angioimmunoblastic Lymphoma ” and such claim was repudiated vide letter dated 26.06.2018 on the ground of non-disclosure and concealment of facts.

Discharge Summary  goes to show that complainant/insured had surgical history of kyphoplasy in 2009 for L3 vertebral facture. The medical history details of Guillain Barre Syndrome was not revealed while taking the policy in the proposal form. Complainant did not disclose such fact before taking Insurance Policy. Needless to add that Dr. Soumya Bhattacharya of Apollo Gleneagles Cancer Institutes issued a certificate dated 12.09.2018.  We have gone through the said certificate. Dr. Bhattacharya opined that current treatment of Mr. Dutta/insured has no relation with “lymphoma”. Complainant did not examine Dr. Bhattacharya to prove his opinion.

Clause 3 (m) of the Insurance Policy goes to show that “if any claim is in any manner dishonest or fraudulent or is supported by any dishonest of fraudulent means or devices, whether by you or any insured person or anyone acting on behalf of you or an insured person then this policy shall be void and all benefits paid under it shall be forfeited”.

Clause 3 (t) of the insurance policy goes to show that “We may terminate this policy on grounds of misrepresentation, fraud, non disclosure of material facts, or non-cooperation by you or any insured person or anyone acting on your behalf or on behalf of an insured person. ”

The terms & conditions of the policy must be given paramount importance and it is not open for any court to add, delete or substitute any words therein. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss-suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed to determine the extent of liability of the insurer. Thus, we have no scope to bypass the policy condition under any circumstances. As such, rejection of claim and cancellation of policy of the complainant is justified. In our opinion, there is no deficiency in services for rejecting the claim and cancellation of policy of  the complainant on the part of the OPs 1 & 2. Thus, the complainant is not entitled to get any relief as prayed for. Hence, we answer only point accordingly.

In view of the foregoing discussion, the OPs cannot be fastened for deficiency in service in terms of law or policy terms & conditions. Thus, the consumer complaint is dismissed on contest against the OPs.   However,  no order as to costs.

A copy of this order as per statutory requirements be sent to the parties free of charge.