SMT. RAVI SUSHA: PRESIDENT
Complaint filed this complaint Under Section -12 of Consumer Protection Act 1986 seeking an order directing the opposite party to pay Rs. 80000/- to the complainant as hopilization amount incurred to him and Rs. 20000/- being compensation for mental agony.
The brief facts of the complainants case is that the complainant has taken Health Insurance under the scheme Senior Citizen Red Carpet Health Insurance
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Policy. The policy taken in the year 2014. The said policy was renewed up to 2017. The complainant has taken the 1st policy on 28/11/2014. After the expiry of the said policy, it was renewed for the period 28/11/2015 to 27/11/2016. During the month of June 2016, the complainant had a pain redness and swelling over the left lower lob (celf), and he was having pain while walking. So the complainant was admitted in the Aster Mims Hospital, Calicut on 21/06/2016. From there it was diagnosed Bilateral Left Leg Cellulites and lower respiratory tract infection with cirrhosis of liver with portal hypertension with secondary diagnosis as Umbilical Hernia. The complainant was discharged on the hospital on 01/07/2016 with an advice to continue the treatment. Immediately after the discharge from the hospital the complainant submitted a claim before the opposite party, claiming the hospitalization charge and actual medical bill along with claim form. The opposite party in the course of process of claim requested the complainant to submit the some more documents required by them. The complainant forwarded the required documents and consent letter as required by the opposite party. Even after the receipt of the above documents, the opposite party requested to submit regarding the consultation investigation done on 20/11/2014. I have already submitted the photocopy of the prescription on 20/11/2014. Even after the receipt with the staff of the opposite party, vide their letter dated 10/02/2017 informed that the documents are not submitted, hence the claim rejected. The complainant further submitted that the original policy expired and the same was renewed subsequently. During the existence of the renewal policy complainant felt sick and admitted in the hospital. The complainant was diagnosis as Bilateral Left Leg Cellulites, it is not a pre existing disease. All the original hospital bills and discharge summary with the opposite party. The opposite party has rejected the claim unilaterally without assigning any reason. The complainant has hired the service of opposite party for consideration and opposite party promised to reimburse whatever the expense incurred for hospitalization. The complainant has entered into a contract with opposite party and it is only on account of the deficiency of service by opposite party. The complainant has to suffer severe mental agony and loss. Now the complainant is convinced that the opposite party will not make any payment hence the
this complaint
While pending of this complaint, the complainant expired. So the Legal heirs
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wife and two sons were impleaded as additional complainants 2 to 4. 3rd additional
complainant filed chief affidavit and 10 documents.
After receiving notice opposite party filed version admitted that the complainant has taken policy of Senior Citizen Red Carpet Insurance Policy from the opposite party for the period from 28/11/2014 to 27/11/2015 and renewed up to 27/11/2017 for a sum insured of Rs. 200000/-. It is submitted that at the time of availing the policy the complainant was supplied with the terms and conditions of the policy. It is also admitted by opposite party that the insured got admitted at MIMS Hospital, Calicut on 21/06/2016 was diagnosed with Bilateral LL Cellulitis, Lower respiratory tract infection, Cirrhosis of liver with portal hypertension. After treatment, she was discharged from the hospital on 01/07/2016. After discharge from the hospital, the insured submitted a claim form along with medical bills and lab reports to the insurance company claiming reimbursement of the medical expenses incurred by him in the hospital. It is submitted that on going through the discharge summary submitted along with the claim, the treating doctor had noted in the history column that the patient is a known case of cirrhosis of liver with portal hypertension, diabetes mellitus. In order to process the claim submitted by the complainant, this respondent sent a letter dated 13/09/2016, requested the insured to furnish the first consultation details of liver cirrhosis when it was diagnosed with investigation reports at that time, consultation details/ treatment details of cellulitis before this admission to the insurance company. But the insured had not furnished the information sought by the company. Company had received a letter on 20/10/2016 wherein the insured stated that he had no pre-existing diseases. It is submitted that the information provided by the insured to the insurance company is totally incorrect. The insurance company had conducted an investigation on this matter and it was found that the complainant had undergone treatment at Indira Gandhi Co-operative Hospital, Thalassery on 20/11/2014. When the insurance company asked the complainant to submit the details of the consultation at Indira Gandhi Co-operative Hospital, the complainant did not produce the same and tried to suppress the records from the insurance company. Instead of submitting the details regarding his earlier consultation, the complainant
made a false statement to the opposite party to the effect that he was not suffering from any previous illnesses. Since the insured had not submitted the additional
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documents required by the opposite party, it was not possible for the insurance company to process the claim submitted by the insured in proper way and had no
option but to repudiate the claim vide its letter dated 09/01/2017. The claim was repudiated, as insured violated condition No. 4 of the policy. It is submitted that a
contract of insurance is based on the principles of utmost good faith. The insurer and the insured are bound by the terms and conditions of the insurance contract. As per the terms and conditions of the Senior citizen red carpet insurance policy under the head exclusions. The exclusions clause No.5 stipulates that “50% of each and every claim arising out of pre-existing diseases as defined and 30% in case of all other claim are to be borne by the insured. “As per the Senior Citizen Policy, there will be a 50% co-payment in case of pre-existing disease, sublimits and deductions are applicable. There is no deficiency in service on the part of the opposite party in the matter of processing the claim of the insured. As there is no deficiency of service on the part of the opposite party, the complainant is not eligible to claim a get the compensation from the opposite party. Hence prays for the dismissal of the complaint.
The Senior Executive Legal, of opposite party filed chief affidavit and document. At the evidence stage 3rd complainant was examined as PW1 and Ext. A1 to A10 were marked on their side. From the side of opposite party Senior Executive legal was examined as Dw1 and Ext B1 to B9 were marked. Both witnesses were cross-examined for the rival parties.
At the argument stage Learned Counsels of both parties have filed written argument notes. The Learned Counsel of complainant has made oral argument also. We have considered the submissions of both Learned Counsels of complainant and opposite party and carefully perused the records brought before us.
Here the undisputed facts are the taking of policy by the complainant of Senior Citizen Red Carpet Insurance Policy of opposite party – 1from 28/11/2014 to 27/11/2015 and renewed up to 27/11/2017. It is also an admitted fact that during the policy period ie on 21/06/2016 the complainant was admitted in the Aster Mims Hospital Calicut and from there Bilateral left leg cellulites and lower respiratory tract infection with cirrhosis of liver with portal hypertension was diagnosed and with
secondary diagnosis as Umbilical Hernia. It is also a fact that after discharge from the hospital complainant has submitted claim form (Ext. B2) before the opposite party for reimbursement of hospitalization expenses and it was repudiated by opposite party
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vide Ext B9 on the ground of suppression of material facts ie “the treatment records reveal that the patient was suffering from HTN since 3 years. The policy commences from 30/05/2014. Existing illness suppressed while taking policy. In the proposal form, you have not revealed the previous health related complaints. A health insurance policy is issued in good faith after assessing the health condition of a proposer based on the health related facts stated in the proposal form. Obtaining a policy without disclosing the full facts on health of a person would make the insurance policy void ab initio. We therefore regret our inability to admit your claim for the insured person under the above policy and we hereby repudiate your claim” .
In the instant case the question to be decided is whether the repudiation of claim of the complainant made by the opposite party is Justifiable?
The opposite party’s contention is that the health state of the insured was suppressed in the Ext B1 proposal form. As per Ext A4 the insured had previous consultation from Indira Gandhi Hospital, Thalassery on 20/11/2014 which was prior to the inception of policy. Thus there is suppression of material facts regarding state of Health of the insured. Opposite party further pleaded that after receipt of claim form on the basis of investigation since they asked the complainant to submit Ext A4 details of consultation at Indira Gandhi Co-operative Hospital the complainant did not
Submit the above said records before them.
On the other hand complainant submitted that on the demand of opposite party, he has already submitted the photocopy of the prescription on 20/11/2014 and even after the receipt of photocopy of Ext A4, opposite party submitted that the documents were not given. The Learned Counsel of complainant submitted that the treatment undergone by the complainant as per Ext A4 has no connection with the present claim. It is further submitted that the condition No -4 in the Ext A1 policy is not at all applicable in this case because there is no relevancy in respect of document demanded by the opposite parties.
Here on perusal of condition No – 4 (4) of Senior Citizens Red Carpet Health Insurance Policy (Ext A1 Policy). The Insured persons shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and “shall also give the company such additional information and assistance as the company may require in dealing with the claim. It is also mentioned that the
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company reserves the right to call for additional documents wherever required. Since a contract of insurance is based on the principles of utmost good faith, the insurer and insured are bound by the terms and conditions of the insurance contract. So as per condition No- 4 (4) of Ext A1 policy opposite party have liberty to give direction to the complainant to produce additional document which they require. So we cannot blame opposite party in sending Ext B6. The complainant raised another contention that he had submitted photocopy of Ext A4 to the opposite party. But on perusal of Ext B7 the reply letter sent by the complainant to the opposite party dated 20/10/2016 reveals that from the sentence in Ext B7 “the discharge summary report (A30 clearly proves that bilateral cellulites has not effected with me as a disease ever before”, the complainant did not sent Ext A4 treatment record dated 20/11/2014 to the opposite party.
Further from Ext A4 we can realize that the complainant had undergone treatment in Indira Gandhi Co-operative Hospital, Thalassery dated 20/11/2014 which was suppressed by the complainant in Ext. B1 proposal form. The complainant submitted that the Ext A4 treatment has no connection with the present claim. Our view is that complainant should have proved the said point through the treated doctor. Lack of consistent evidence we presume that the complainant had pre-existing disease.
Opposite parties next contention is that in case of Senior Citizen Red Carpet Insurance Policy, medical examination is not required as the entry stage must be above 60 years of age and as per the terms and conditions of the policy in the case of pre-existing decease insured is eligible only 50% of the claim. The complainant submissions with regard to this contention is that the agent who canvassed the policy has not stated the terms and conditions to the insured complainant at the joining time of policy. But we can see that complainant himself produced the terms and condition of policy before the Forum and marked it as Ext A1. So the complainant could not dency their own document.
Thus from the above discussion and from the terms and conditions of the policy taken by the complainant, the complainant is entitled to get 50% of the claim as reimbursement for the hospitalization expenses. Here the treatment bill was amounting to 73803/- from Aster MIMS Hospital. Hence complainant is eligible to get
½ of Rs 73803/- ie Rs. 360902/- as reimbursement of hospitalization expenses.
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In the result complainant is allowed in part. Opposite party is directed to pay Rs. 36902/- to the additional complainants, within one month from the date of receipt of this order failing which the amount Rs. 36902 carries 12% from the date of this order till realization. Opposite parties are further directed to pay Rs. 15000/- as compensation.
Exhibits
Ext A1 – Policy
Ext A2 – Scanning Report
Ext A3 – Discharge Summary
Ext A4 – Indira Hospital Gastrologist
Ext A5 – Letter issued by star Health & Allied Insurance Co. Ltd
Ext A6 – Letter issued by Star Health & Allied Insurance Co. Ltd dated 28/01/2017
Ext A7 – Letter issued by Star Health & Allied Insurance Co. Ltd dated 10/02/2017
Ext A8 – Lawyer notice with postal receipt
Ext A9 – Acknowledgement card (Original)
Ext A10 – Medical bills (Rs. 73803)
Ext B1 – Original Proposal Form
Ext B2 – Original Claim Form
Ext B3 – Details of Bills claimed dated 25/07/2016 along with bills amounting to
Rs. 73803/- submitted Ramachandran.K.K to the Opposite party.
Ext B4 – Original Discharge Summary dated 01/07/16 issued by Aster MIMS,
Kozhikode.
Ext B5 – Copy of letter sent by opposite party to complainant dated 13/09/2016.
Ext B6 – Copy of 1st reminder letter dated 04/10/2016.
Ext B7 – Letter sent by complainant dated 20/10/2016 along with treatment
documents.
Ext B8 – Copy of policy schedule and condition
Ext B9 – Copy of reputation letter dated 09/01/2017
Sd/- Sd/- Sd/-
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
/Forwarded by Order/
Senior Superintendent
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