Order No. 21 dt. 15/11/2017
The case of the complainant in brief is that the complainant was the holder of mediclaim policy with the National Insurance Co. Ltd. and the same was ported to o.p. to its company being policy no. 30168448201300 with the sum assured of Rs. 3,00,000/- for the period from 29/01/2013 to 28/01/2014. The complainant all on a sudden became ill on 15/06/2013 and he was advised for medication at Mumbai. Accordingly the complainant was admitted to Asian Health Institute, Mumbai on 25/06/2013 and underwent surgical intervention of cardio-pulmonary bypass under the supervision of Dr. Ramakanta Panda. The complainant was discharged on 06/07/2013. The complainant after release from the hospital claimed for medical reimbursement from the o.p. but the o.p. 1 repudiated the claim of the complainant on the ground of patient is having a history of hypertension since 8 years and past history of CVA-TIA in 2007 but it was not disclosed at the time of inception of the policy. Thus for suppression of material information the claim of the complainant was not entertained. The complainant further stated that a separate claim was lodged with another insurance company namely viz. National Insurance Co. Ltd. who settled the claim for Rs. 3,06,720/- (S A Rs. 4,00,000/-) by making payment to the complainant within a period of 20 days from the date of submission. On the basis of the said fact the complainant filed this case praying for direction upon the o.p.s for releasing the fund of Rs. 3,00,000/- to the complainant for reimbursement of the medical bills and also prayed for compensation of Rs. 5,00,000/- and Rs. 20,000/- for litigation cost.
O.p.s contested the case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant applied for portability of such medical policy and accordingly the insurance policy was shifted from National Insurance Co. Ltd. to Max Bupa Health Insurance Co. Ltd. By entering into such insurance policy with the insurance company the complainant agreed, acknowledged and accepted the terms and conditions provided in such insurance policy. The insurance company received a claim for reimbursement of expenses incurred during hospitalization from 25/06/2013 to 06/07/2013. On going through the discharge summary of hospitalization it was found that the complainant is a known case of hypertension since 8 years and had also suffered from CVA-TIA, i.e. cardio-vascular accident and TIA, i.e. transient ischemic attack in 2007. The discharge certificate dt. 06/07/2013 disclosed that the complainant was treated for calcific aortic steno sis with aortic valve replacement. Both are heart conditions and if the insurance company had known about the heart disease and hyper-tension of the complainant the insurance policy would not have been issued at all. In view of such background of the case and for non-disclosure of any pre-existing disease is a valid ground for repudiation of any claim and termination of the insurance policy which is communicated to every policy holder at the very beginning. In view of facts and circumstances above the o.p.s prayed for dismissal of the case.
On the basis of the pleadings of the respective parties following points are to be decided :-
- Whether the complainant was insured with the insurance company with the relevant point of time ?
- Whether there was suppression of any pre-existing disease at the time of obtaining policy ?
- Whether there was any justifiable cause for repudiation of the claim of the complainant ?
- Whether there was any deficiency in service on the part of the o.p.s ?
- Whether the complainant will be entitled to get the relief as prayed for ?
Decision with reasons :-
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. Lawyer for the complainant argued that the complainant was the holder of mediclaim policy with the National Insurance Co. Ltd. and the same was ported to o.p. to its company being policy no. 30168448201300 with the sum assured of Rs. 3,00,000/- for the period from 29/01/2013 to 28/01/2014. The complainant all on a sudden became ill on 15/06/2013 and he was advised for medication at Mumbai. Accordingly the complainant was admitted to Asian Health Institute, Mumbai on 25/06/2013 and underwent surgical intervention of cardio-pulmonary bypass under the supervision of Dr. Ramakanta Panda. The complainant was discharged on 06/07/2013. The complainant after release from the hospital claimed for medical reimbursement from the o.p. but the o.p. 1 repudiated the claim of the complainant on the ground of patient is having a history of hypertension since 8 years and past history of CVA-TIA in 2007 but it was not disclosed at the time of inception of the policy. Thus for suppression of material information the claim of the complainant was not entertained. The complainant further stated that a separate claim was lodged with another insurance company namely viz. National Insurance Co. Ltd. who settled the claim for Rs. 3,06,720/- (S A Rs. 4,00,000/-) by making payment to the complainant within a period of 20 days from the date of submission. On the basis of the said fact the complainant filed this case praying for direction upon the o.p.s for releasing the fund of Rs. 3,00,000/- to the complainant for reimbursement of the medical bills and also prayed for compensation of Rs. 5,00,000/- and Rs. 20,000/- for litigation cost.
Ld. Lawyer for the o.p.s argued that the complainant applied for portability of such medical policy and accordingly the insurance policy was shifted from National Insurance Co. Ltd. to Max Bupa Health Insurance Co. Ltd. By entering into such insurance policy with the insurance company the complainant agreed, acknowledged and accepted the terms and conditions provided in such insurance policy. The insurance company received a claim for reimbursement of expenses incurred during hospitalization from 25/06/2013 to 06/07/2013. On going through the discharge summary of hospitalization it was found that the complainant is a known case of hypertension since 8 years and had also suffered from CVA-TIA, i.e. cardio-vascular accident and TIA, i.e. transient ischemic attack in 2007. The discharge dt. 06/07/2013 disclosed that the complainant was treated for calcific aortic steno sis with aortic valve replacement. Both are heart conditions and if the insurance company had known about the heart disease and hyper-tension of the complainant the insurance policy would not have been issued at all. In view of such background of the case and for non-disclosure of any pre-existing disease is a valid ground for repudiation of any claim and termination of the insurance policy which is communicated to every policy holder at the very beginning. In view of facts and circumstances above the o.p.s prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant had the policy with the insurance company at the relevant point of time. Before applying for the policy the complainant was provided with the policy kit under clause 4, details exclusions “we shall not be liable under this policy for any claim in connection with or respect of the following :
- Pre-existing conditions.
- Benefits will not be available for pre-existing condition until 48 months of continuous coverage have elapsed since the inception of the first policy with us.”
Subsequently the complainant made a reimbursement claim for the treatment from 25/06/2013 to 06/07/2013. The claim of the complainant was for the treatment of heart disease in CMRI, Kolkata from 30/05/2013 to 05/06/2013. Thereafter he was again hospitalized for the same ailment from 19/06/2013 to 20/06/2013. The discharged summary of Asian Health Institute, Mumbai specifically mentions that the past history of the complainant was a case of hypertension since 8 years and had also suffered from CVA-TIA, i.e. cardio-vascular accident and TIA, i.e. transient ischemic attack in 2007. It was also disclosed that the complainant was treated for calcific aortic steno sis with aortic valve replacement. Both are heart ailments.
It is relevant to mention here that at the time of entering into the insurance policy the complainant was under obligation to reveal everything about his past medical history, but he did not reveal and/or disclose his medical history. The complainant suppressed his health condition at the time of obtaining policy and as per clause 4(a) of the terms and conditions of the insurance policy clearly states that benefits will not be available for the pre-existing disease until 48 months of continuous coverage have elapsed since the inception of the first policy with the insurance company, i.e. the o.p. 1.
In view of such facts and circumstances as stated above we hold that the complainant there are clauses which require 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 medical policy cannot be said to be arbitrarily done.
We have perused the judgements reported in AIR, 1999 Supreme Court 3252 Oriental Insurance Co. Ltd. vs. Sony Cheriyan, Diwan Sundarlal vs. Oriental Insurance Co. Ltd., Vikram Greentech Ltd. vs. New India Assurance Ltd. and another judgement S. C. Surana vs. National Insurance Co. Ltd. delivered on 04/05/2017 as cited from the cite of o.ps.
Perused the decisions reported in 2017 CPJ 262 NC, 1 (2017) CPJ 266 NC, (2016) CPJ 339 NC and 20016 CPJ 341 NC as cited by the Ld. Lawyer for the complainant.
Having regard to the facts and circumstance of the case we hold that the case filed by the complainant has got no merit and the complainant will not be entitled to get the relief as prayed for.
Thus all the points are disposed of accordingly.
Hence, it is ordered,
that the case no. 391 of 2014 is dismissed without cost against the o.p.s.
Supply certified copy of this order to the parties free of cost.
