CONSUMER DISPUTES REDRESSAL FORUM,PALAKKAD
Dated this the 30th May, 2016
PRESENT : SMT. SHINY.P.R, PRESIDENT
: SMT. SUMA. K.P, MEMBER
: SRI. V.P.ANANTHA NARAYANAN, MEMBER
Date of filing : 22/07/2015
CC /104/2015
Indira.P.A,
W/o.Sankarankutty,
Eyyala House, Thiruvazhiyode P.O,
Ottapalam Taluk, Palakkad : Complainant
(By Adv.M.Radhika)
Vs
The Manager, : Opposite party
Health Insurance L.I.C of India,
(Divisional Office), Ernakulam D.O,
Health Insurance Department,
Jeevan Prakash,
M.G.Road, Ernakulam
(By Adv.T.P.George)
O R D E R
By Smt. Suma. K.P, Member,
The complainant has taken a health Insurance policy named Jeevan Arogya Health Insurance Policy from the opposite party on 24/08/2011 for a period of 20 years. Yearly premium payable under it was Rs.3,670/- which the complainant was paying regularly. As per the terms and conditions applicable under the policy the opposite party is bound to meet all medical expenses which she is likely to incur in the event of her hospitalization for a period of 24 hours or more at a time for the treatment of any disease or sickness as defined in the policy conditions provided the disease of sickness is not a pre existing disease at the time of issuance of the policy. She was medically examined at Lakshmi Hospital, Palakkad to prove the medical fitness before issuance of the policy and satisfied by the medical examination reports the policy was issued to her by the opposite party. Subsequently after a period of 3 years, during 2014 February pain developed on her left knee which became unbearable in the due course of time. She approached the MIMS hospital, Kozhikode for consultation with the Orthopaedic Surgeon of the hospital, who after examining her, found that the cause of pain was due to the decaying of the knee bone and therefore recommended total knee transplantation for curing it. Accordingly the complainant got admitted in the hospital on 12/05/2014 and the surgery was conducted on 14/05/2014. The complainant informed the opposite party about it which was approved and advised her to undergo surgery promising to settle the medical bills directly with the MIMS hospital authorities at the time of her discharge from the hospital after the surgery. She was discharged from the hospital after surgery on 23/5/2014 and had incurred an amount of Rs.1,20,000/- which the opposite party was bound to settle with the MIMs hospital directly as per the terms and condition of the policy and also as per the promise made to the complainant. But the opposite party refused to settle the claim. So the complainant had to settle it with the hospital authorities. After discharge the complainant went to the office of the opposite party and filed a claim petition before it demanding reimbursement of the amount paid by her to the hospital towards the surgery charges. But the opposite party rejected the claim stating that it is a pre existing illness irrespective of prior medical treatment and advice. Against the rejection order the complainant filed appeal before the Manager, Health Insurance Ernakulum on 23/10/2014. The same objection was raised by the opposite party in the appeal also. According to the opposite party the complainant was suffering from coronary and artery diseases and was also having knee problems to her left leg for a long period of time since 2007 and had gone to the MIMS hospital, Kozhikode for treatment of those diseases during that period of time. The complainant was willfully suppressing these facts and induced the opposite party to issue the policy violating the terms and conditions of the policy.
Hence the contract of the policy between the parties is a void contract and the complainant is not entitled to get any benefits under the same. The complainant had not received any relief from the appeal and hence he had approached before this forum praying for an order directing the opposite party to reimburse an amount of Rs.1,12,000/- with 12% interest and also to pay Rs.2lakhs compensation for the mental agony suffered by her due to the deficiency of service on the part if the opposite party besides the cost of this proceedings.
Notice was issued to the opposite party for appearance. Opposite party entered appearance and filed version with the following contentions.
Opposite party admits that complainant had taken a policy named Jeevan Arogya policy with medical insurance coverage of Rs.1lakh for the period from 2011-2032 with an annual premium of Rs.3,675/-. The policy was issued based on the declarations made by the complainant in the proposal form. The “welcome kit” given to the policy holder form part of the policy bond in a conditions and privileges under the Jeevan Arogya Policy. The policy is subject to certain exclusion process wherein no benefits are available and no payment will be made by the cooperation for any claims under this policy. The major surgical benefit is payable for eligible surgeries which are mentioned in the conditions and privileges of the policy subject to the terms and condition in the policy. As per the Jeevan Arogya Privileges and conditions “total knee replacement surgery” is not covered under the policy. Hence the claim for the complainant for major surgical benefits is rejected. The allegation of the complainant that all medical check-up were done and the policy was issued only after the opposite party was convinced that she had no existing illness is not correct. Medical check-ups conducted at the time of taking policy was to know the general health conditions and it was the duty of the policy holder to reveal any past treatment undergone and the details of the pre existing diseases. In this case the complainant had not disclosed the details of previous ailments at the time of medical checkups or at the time proposal stage, thus initiating the contract. Since the discharge summary of the complainant shows that complainant was admitted with the complaints of bilateral knee pain more on the left side for the last few years opposite party requested the complainant by a letter dtd.09/05/2015 to produce all medical records from MIMS Hospital from 2007, but the complainant did not produce those documents. Opposite party had also investigated the matter and it was found that on many occasions the complainant was under treatment at MIMS hospital for abdominal discomfort and coronary artery disease. Hence the claim for hospital cash benefit was also rejected. Opposite party denied the allegation in the complaint that they had promised to settle the bills of the complainant directly to the hospital. Pre-existing medical condition is excluded and no benefits are available and no payment will be made by the opposite party. Hospital records will show that the complainant was suffering from coronary artery diseases and knee problem for a long time. This is a clear case of pre existing disease. The complainant have willfully suppressed to the material information and took the policy by violating the terms of the policy. Hence the complainant’s claim under the policy was rejected by the opposite party. Hence the complaint has to be dismissed.
Complainant filed chief affidavit along with documents. Opposite party also filed proof affidavit and one application to call for documents from MIMS hospital Kozhikode and also to summon a witness. IA was allowed and the witness was summoned from MIMS hospital. The documents produced from the MIMS hospital was marked as Ext.C1. Ext.A1 to A7 was marked from the part of the complainant. Ext.B1 to B5 was marked from the part of the opposite party. The witness was examined as DW1. Evidence was closed and matter was heard.
The following issues are to be considered.
- Whether there is any deficiency of service on the part of the opposite party?
- If so, what are the reliefs and cost?
ISSUES 1 & 2
We had perused the affidavits as well as documents produced before the Forum. The objection raised by the opposite party was that the complainant has pre existing disease or illness at the time of issuing the policy. The complainant submits that the opposite party has raised this contention on the basis of a non existing medical report. On the other hand facts and materials appearing on record shows that contention of the opposite party that she had pre existing illness at the time of issuing the policy is false. Complainant states that the policy was given to her on the basis of the medical examination done at Lakshmi Hospital, Palakkad at the instance of the opposite party. As per the report her health condition was found to be absolutely satisfactorily. The medical report is also available with opposite party. Ext.A4 was produced by the complainant which is the hospital treatment form issued from the MIMS hospital at the instance of the opposite party in the form supplied by it. It contains all necessary particulars regarding which the opposite party is seeking information. The informations are given by the Orthopedic surgeon of the hospital under whom the complainant was under treatment from 12/5/2014 to 23/5/2014 under his signature. The column no.9,10,11,12 & 13 proves that the disease suffered by the complainant was not a pre-existing disease or congenital in nature. It was alleged by the opposite party that in the version and chief affidavit that they had conducted investigation about it and found that on many occasions the complainant was under treatment for these diseases at the MIMS hospital Kozhikode during 2007. In the appeal filed by the complainant before the Manager, Health Insurance, Ernakulam, the opposite party directed the complainant to produce alleged medical records given to her from the hospital as per letter dated 9/5/2015 which was marked as Ext.A7. Complainant submits that she had any coronary or artery diseases nor she had any knee problem to either one of her legs during 2007 or there about and hence she had no occasion to seek medical treatments from the MIMS hospital for those diseases. So she was not in a position of the alleged medical report. Hence she could not produce it as directed in Ext.A7. She had replied showing all these facts which was marked as Ext.A2. In this connection we had also perused section 45 of the Insurance Act 1938 which is incorporated in Ext.B2 produced by the opposite party. Under the section the opposite party insurer is not entitled to content after the expiry of two years from the date on which the insurance was effected that the statements made in the proposal for issuing the policy were in accurate or false, or suppressed or was fraudulently made by the policy holder and that the policyholder knew at the time of making it that the statements were false or that it was suppressed. In this case the policy was issued on 24/8/2011 the objection is made by the opposite party after a period of 3 years during the month of September 2014. It therefore offends session 45 of the act. Moreover there is nothing to show that the statements made in the proposal form for the reasons already submitted were false and opposite party was induced to issue the insurance policy. The evidence tendered by DW1, the doctor on the basis of the medical report produced by him also establishes the complainant’s case. According to DW1 “a few years duration” stated in the discharge summary regarding the knee pain suffered by the complainant means less than two years which proves that she was not suffering from knee pain for a long period since 2007 onwards. Coronary and artery diseases have no connection with the knee pain also. The medical report produced by him marked as C1 from the hospital does not contain any particulars regarding the treatment alleged to have been undergone by her during 2007 of there about. Hence the contention of opposite party that the claim of the complainant was rejected on the ground that it is a pre existing disease cannot be taken into consideration. The opposite party has admitted in para 4 of the chief affidavit that the case of Jeevan Arogya Insurance Policy provides various benefits to the policy holders under Ext.B2 produced by them. These benefits are 1) hospital cash benefit 2) major surgical benefit 3) day care procedure benefit 4) Other surgical benefits. The contentions of the opposite party is that the relief sought under item No.2 namely major surgical benefit which covers 140 surgeries as shown in Ext.B2 cannot be granted since it does not include knee transplantation surgery. The relief sought by the complainant can be granted only under item No.4 namely other surgical benefits. It applies to the treatment of all diseases including knee transplantation surgeries necessitated due to other reasons. The only conditions to be satisfied for the application of the scheme is hospitalization for a period of 24 hrs or more in a hospital situated in India for treatment of sickness as defined in clause 1 sub clause XXIII in Ext.B2. Under it sickness means or includes treatment of diseases, illness and surgery in a hospital by a physician in a hospital. Knee pain is a sickness as defined in it which as in this case required knee transplantation surgery in a hospital for which the complainant was admitted at MIMS hospital Kozhikode on 12/5/2014. It is not subjected to any exclusion. Hence the complainant is entitled to get reimbursement of the amount under other surgical benefits which states that a daily benefit equal to two times the applicable daily benefit, shall be payable by the corporation, regardless of the actual cost incurred for each continuance period provided any such part stay exceeds a continuous period of 4 hrs of hospitalization. In this case the complainant was admitted in the hospital from 12/5/2014 and was discharged on 23/5/2014. Hence the complainant is entitled to the benefits available under other surgical benefits mentioned in Ext.B1 policy. Under this clause, the complainant is entitled to get a daily benefit equal to two times the applicable daily benefit if hospitalization exceeds a continuous period of 24 hours within the cover period. Rejecting the claim under the above clause amounts to deficiency of service on the part of the opposite party. Hence the complaint is allowed in part.
In the light of the above discussion, we direct the opposite party to pay an amount of Rs.24,000/- (Rupees Twenty four thousand only) to the complainant along with Rs.5,000/- (Rupees Five thousand only) as compensation for the mental agony suffered by him. We also direct the opposite party to pay Rs.2,000/- (Rupees Two thousand only) towards cost of this litigation. The afore said amount shall be paid within 1 month from the date of receipt of this order failing which the complainant is entitled to get 9% interest for the said amount from the date of order till realization.
Pronounced in the open court on this the 30th day of May, 2016.
Sd/-
Shiny.P.R
President
Sd/- Suma. K.P
Member
Sd/-
V.P. Anantha Narayanan
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext.A1 –LIC Jeevan Arogya Policy document dtd.24/08/2011(Original).
Ext.A2 – True copy of reply notice
Ext.A3- Photocopy of discharge summary dtd.23/05/2014
Ext-A4- Photocopy of hospital treatment form dtd.01/9/2014
Ext.A5- Photocopy of claim rejection letter dtd.01/9/2014
Ext.A6-Application of Right to information Act
Ext.A7-Registered letter dtd.9/5/2015 in the name of complainant.
Witness marked on the side of complainant
Nil
Ext.C1 series –True copy of Discharge summary
Exhibits marked on the side of opposite party
Ext.B1- Proposal form dtd.15/07/2011 (Photocopy)
Ext.B2-Copy of LIC’s Jeevan Arogya conditions and privileges brouchure
Ext.B3-Copy of letter dtd. 9/5/2015 issued to complainant by the opposite party
Ext.B4-Discharge summary dtd.23/05/2014 from MIMS Hospital (Photocopy)
Ext.B5- Claim Rejection Letter dtd.13/05/2015 (Photocopy)
Witness examined on the side of opposite party
DW1-Dr.George Abraham
Cost Allowed
Rs.2,000/- as cost.
