Order No.  19  dt.  02/05/2017

        The fact of the case in brief is that the complainant availed of a health insurance policy being no. 10058402 from o.p. She was admitted in Purnam Medicare Lansdowne Nursing Home on 04/10/2014 at 12.17 p.m. The complainant was admitted due to high fever and pain in right flank with urinary retention. She was admitted under the Dr. Gautam Basu and was treated by Dr. P. K. Chakraborty. After admission the complainant was put on intravenous antibiotics and after U.S. scan and D. T. Scan she was finally diagnosed with acute pyclonefritis and severe infection in her right kidney. Complainant was treated with continuous intravenous antibiotics for 12 days. The complainant was diagnosed as diabetics for the first time in April, 2014 and since then complainant was put on low dose of medicine prescribed by Dr. P. Chakrabarty. The total expense of hospitalization was Rs. 87,000/- and accordingly complainant made a claim before o.p. for that amount. O.p. 1 repudiated the claim on the ground that complainant was suffering from diabetes since 5 years but the true fact is she was suffering from diabetes for last 6 months. Hence the application praying for re-imbursement of medical expenses of Rs. 87,000/- along with compensation of Rs. 2,00,000/- and litigation cost of Rs. 10,000/-.

        O,p.s appeared before this Forum and contested the case by filing w/v. In their w/v o.p.s denied all material allegations inter alia stated that the ailment for which the complainant was hospitalized is due to pre-existing condition of diabetes mellitus. In the light of said facts the claim of the complainant was duly rejected as per policy terms and conditions. At the time of inception of the policy the complainant was specifically asked to fill up the proposal form with correct information and disclosures pertaining to her health status. However, the complainant chose otherwise for reasons best known to her. Complainant has made incorrect disclosures about her health status in the pre-policy medical examination. The declaration made by the complainant under the heading ‘Endocrine glands and Exocrine glands’ was incorrect. The pre-existing condition of Diabetes Mellitus cannot be detected since the complainant is already on medication. It was not disclosed in the proposal form at the time of inception of the policy. The present complaint is not maintainable since the policy in question was obtained by the complainant by concealment of material facts. The contract of insurance is a contract of utmost good faith, i.e. doctrine of Uberimma Fide. The complainant had not disclosed about the ailments suffered by her prior to obtaining the policy in question. Thus the present complaint is liable to be dismissed since there is no deficiency on the part of the insurance company. Hence, o.p.s prayed for dismissal of complaint with cost.

Decisions with reasons :-

We have gone through the pleadings of the respective parties and evidence in particular.

It is admitted fact that the complainant’s husband had taken a Health Insurance Policy (CARE) bearing no. 10058402 in the name of complainant effective from 28/12/2013 till 27/012/2014 for sum insured of Rs. 4,00,000/-. The policy was provided for the benefit subject to specific terms and conditions as stipulated in the policy. At the time of taking above mentioned policy the complainant’s husband had submitted proposal form duly filled and submitted by him. The proposal form was signed by Dr. Gautam Basu (Proposer), husband of the complainant for the insured Sharmila Basu (present complainant). Complainant admitted in Lansdowne Nursing Home (a unit of Purnam) on 04/10/2014 at 12.17 p.m. due to high fever and pain in right flank with urine retention. She was admitted under the Dr. Gautam Basu and was treated by Dr. P. K. Chakraborty. Complainant was discharged from said nursing home on 15/10/2014 at 11 a.m. Accordingly, the complainant placed claim for re-imbursement of medical expenses due to hospitalization before o.p.s. But the o.p.s repudiated the claim by their letter dt. 15/11/2014 and 31/01/2015 on the ground that the complainant was suffering from pre-existing disease, i.e. Diabetes Mellitus. The moot question for consideration is whether the complainant was suffering from pre-existing disease or not. O.p. relied on the document, i.e. ‘Doctor’s treatment orders’ dt. 04/10/2014 issued by Lansdowne Nursing Home wherefrom it revealed that patient ‘is known diabetic for around five years’. But from the discharge certificate it is revealed that the patient was known diabetic and is on medication for six months. But the o.p. did not consider this document. They gave emphasis on the ‘Doctor’s treatment orders’ dt. 04/10/2014. For that reason complainant submitted the certificate issued by treating doctor, Dr. Pradeep Chakraborty. Dr. Chakraborty specifically mentioned that the complainant was diabetic since April, 2014, i.e. for five months prior to admission and she was admitted in Lansdowne Nursing Home with acute pyclonephritis. This was issued by the treating doctor on 16/02/2015. But o.p.s did not rely the discharge certificate and treatment summary as well as the treating doctor’s certificate dt. 16/02/2015. Complainant was admitted to nursing home due to fever for five days which was recurrent in onset and high grade in nature, case of pain in right flank with urinary retention. Moreover o.p. gave emphasis that complainant suppressed her ailments about Diabetes Mellitus. But the policy in question was taken by the complainant on 28/12/2013 and she was diagnosed with diabetes Mellitus five months prior to taking the admission in nursing home on 04/10/2014. So it is clear that she was not suffering from Diabetes Mellitus at the time of taking the policy in question. O.p.s also annexed one document, i.e. ‘Cheque list for Religare Health Insurance’ dt. 17/12/2013 with w/v (exhibit 6). The ‘Confirmation of Medical Examination’ was signed by Dr. Ashis Saha. The necessary tests of the complainant were done by Care Well Diagnostics Centre where it was mentioned that ‘Ref. by Dr. Religare’. Therefore it is crystal clear that all medical tests were done before inception of the policy. After going through all the relevant documents the o.p.s issued the Health Insurance Policy in question. So the question of suppression of material facts does not arise at all.

Upon scrutiny of entire materials on record, we have observed that at the time of inception of the policy the complainant was not suffering from Diabetes Mellitus. She was diagnosed as diabetic after the inception of the policy. Therefore the plea of o.p. cannot be tenable in the eye of law only considering the ‘Doctor’s treatment orders’ dt. 04/10/2014. It is astonishing that they had not relied upon the typed discharge certificate and treatment summary and the treating doctor’s certified dt. 16/02/2015.

In view of above we are in the view that o.p. Insurance Company was certainly deficient in not settling the claim of the complainant, which resulted in causing mental agony and harassment to the complainant. Thus the complainant has substantiated her case and as such she is entitled to get relief.

As a result the complaint succeeds.

Hence,

             ordered,

that the case no. CC/261/2015 is allowed on contest. The o.p.s are directed to pay Rs. 87,000/- (Rupees eighty seven thousand) only towards hospitalization to the complainant. The o.p.s are also directed to pay compensation of Rs. 8,000/- (Rupees eight thousand) only for causing harassment and cost of Rs. 2,000/- (Rupees two thousand) only.

        The o.p.s are directed to give the aforesaid amount within 30 days from the date of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.

        Supply certified copy of this order to the parties free of cost.