SHRI SWAPAN KUMAR MAHANTY, PRESIDENT       

This is an application u/s.12 of the C.P. Act, 1986.

The facts of the case in a nutshell is that the complainants obtained a Insurance Policy (Group Health Insurance) being No. 0000000003687946-01 from the OP SBI General insurance company Ltd. for the period from 15.12.2016 to 11.05.2018. The complainant-2 Anjali Naskar was admitted to OP-4 M/s Ramaiah Memorial Hospital, Bangalore on 21.08.2017 with acute bloodshed from nose  nosebleed essential hypertension and discharged on 25.08.2017. The OP-4 refused to provide cashless benefit to the complainant No.-2 on the basis of the letter of OP-3. The complainants were compelled to incurred Rs. 35,000/- for medical treatment. There is deficiency in service on the part of the OPs. Being aggrieved, the complainants approached this Forum by way of consumer complaint.

The OPs 1 & 2 have contested the case by filing W.V. contending inter alia that the consumer complaint is not tenable under clause-1 of the policy terms and conditions. The specific case of the answering OPs is that the complainant had taken an insurance policy (Group Health Insurance) bearing No. 0000000003687946-01 for the period from 18.02.2015 to 17.12.2017. Prior to taking the policy the complainants submitted proposal form dully filled in and signed by them. That on 21.08.2017 the complainant No.-2 was admitted to OP-4 Hospital at Bangalore with the diagnosis of EPISTAXIS  hemorrhage from nose, Nosebleed, Hypertension with an estimated cost of Rs. 35,000/-. The insured applied for cashless facility to the OP-4 Hospital but the Insurer rejected the cashless request facility vide letter dated 24.08.2017. The complainants did not claim the reimbursement of the hospital expenditure from the answering OPs after discharge the patient from the hospital. The consumer complaint is pre-matured and the complainants have failed  to establish any deficiency in service against  the  OPs 1 & 2. The complainants  have breached the most fundamental principle of insurance namely “Utmost Good Faith”. The complainants should have disclosed the material information before taking the policy. In the instant case complainants did not provide the information prior to obtain Health Insurance Policy. Thus, the answering OPs have prayed for dismissal of the consumer complaint.

The OP-3 Medicare TPS Service Pvt. Ltd. filed W.V. beyond the statutory period of 45 days. As such, W.V was not accepted. Thus, the case has proceeded  ex parte against  the OP-3.

In spite of service of notice OP-4 did not turn up to contest the case. As such, the case has proceeded  ex parte against  the OP-4.

Decision with Reasons

          Both parties have tendered evidence through affidavit. They have also given reply against the questionnaires set forth by their adversaries. Both parties have also filed BNAs. We have examined the entire material on record and also given a thoughtful consideration to the arguments advanced before us.

          Fact remains that the complainants had taken an Insurance Policy (Group Health Insurance) bearing No. 0000000003687946-01 from the OP-1 SBI General Insurance Company Ltd. for the period from 18.12.2016 to 17.12.2017. It is true that complainant No. 2 was admitted to OP-4 Hospital at Bengalore on 21.08.2017 with acute Epistaxis Hemorrhage from nose Nosebleed, Essential (Primary) Hypertension and discharged on 25.08.2017. There is also no dispute  that the OP-4  declined to provide cashless treatment  on the basis of pre-authorization repudiation letter of OP-3 Medicare TPS Services Pvt. Ltd. and  the complainants were compelled to incur Rs.35,000/- for medical treatment of insured Anjali Naskar. Admittedly, the complainants did not claim the reimbursement of the hospital expenditure from the OP-1 after discharge the patient from the hospital.

          Clause 1 of the Insurance Policy read as under:-

1. Pre-existing Diseases Exclusion: -

          Benefits will not be available for any condition ailment or injury or related condition(s) for which Insured has been diagnosed, received medical treatment, has signs and / or symptoms, prior to inception of Insured Person’s first group health policy, until 48 consecutive months have elapsed, after the date of inception of the first group health policy with Insurer.

          This exclusion shall cease to apply if Insured Person has maintained this Health Insurance Policy with Insurer for a continuous period of a full 04 years, without break from the date of Insured’s first group Health Insurance Policy with Insurer.

          This exclusion shall also apply to the extent of the amount by which the limit of indemnity has been increased if the Policy is a renewal of the Health Insurance Policy with Insurer without break in cover. This exclusion shall also apply to any additional health policy that the Insured has purchased from us.

          As per clause 1 of the policy, the claim for Anjali Naskar  falls within four years   waiting period specified  in the policy, whereas  the first policy inception date is 18.12.2015 no benefit shall be payable during first 04 years  of the policy for  the claim which occurs due to pre-existing disease / symptoms. Moreover, Anjali Naskar was admitted to OP-4 hospital on 21.08.2017 for the treatment of hypertensive with Epistaxis managed conservatively with a past history of hypertension since last 10 years as confirmed by the patient party.

          In this context, it is pertinent to mention here that denial of authorization for ceaseless access does not in any way prevent the complainants / Insured from claiming for reimbursement of expenses incurred in the hospitalization and treatment. It is true that the Insured did not claim for reimbursement of expenses of treatment to the OP-1 and admissibility of the reimbursement of expenses will be decided as per terms & conditions of the policy. Thus, the claim of the complainants is premature. Policy represents a contract between the Insured and Insurer and, therefore, the complainants cannot claim anything more what is not provided under the policy documents.

          For the reasons stated hereinabove, we are of the opinion that the complainants have failed to establish their case. As such, complainants are not entitled to get any relief as prayed for.

In result, the case merit fails.

Hence,

Ordered

That the complaint case be and the same is dismissed on contest against the OPs 1 & 2 and also dismissed ex parte against the OPs 3 & 4.There shall be no order as to costs.